Provider Demographics
NPI:1073097275
Name:LOPEZ GARCIA, IVELISSE
Entity Type:Individual
Prefix:
First Name:IVELISSE
Middle Name:
Last Name:LOPEZ GARCIA
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 1:4840 TAMPA DOWNS BLVD LUTZ
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33559
Mailing Address - Country:US
Mailing Address - Phone:939-283-6413
Mailing Address - Fax:
Practice Address - Street 1:4840 TAMPA DOWNS BLVD LUTZ
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33559
Practice Address - Country:US
Practice Address - Phone:939-283-6413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
FL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical