Provider Demographics
NPI:1053845164
Name:LOPEZ, ROLANDO
Entity Type:Individual
Prefix:
First Name:ROLANDO
Middle Name:
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 1:6303 BLUE LAGOON DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-6002
Mailing Address - Country:US
Mailing Address - Phone:786-801-1571
Mailing Address - Fax:786-666-9092
Practice Address - Street 1:6303 BLUE LAGOON DR
Practice Address - Street 2:SUITE 400
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-6002
Practice Address - Country:US
Practice Address - Phone:786-801-1571
Practice Address - Fax:786-666-9092
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician