Provider Demographics
NPI:1043939903
Name:LOPEZ GUTIERREZ, YARILEINE
Entity Type:Individual
Prefix:
First Name:YARILEINE
Middle Name:
Last Name:LOPEZ GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:254 NE 10TH PL
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-2619
Mailing Address - Country:US
Mailing Address - Phone:239-333-9579
Mailing Address - Fax:
Practice Address - Street 1:254 NE 10TH PL
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-2619
Practice Address - Country:US
Practice Address - Phone:239-333-9579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-24
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician