Provider Demographics
NPI:1033800446
Name:LOPEZ, ANDRES DAVID
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:DAVID
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5400 HOLLYWOOD BLVD APT 4
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-6445
Mailing Address - Country:US
Mailing Address - Phone:786-626-5204
Mailing Address - Fax:
Practice Address - Street 1:3625 NW 82ND AVE STE 101
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33166-6633
Practice Address - Country:US
Practice Address - Phone:786-615-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-17
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-271024106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician