Provider Demographics
NPI:1083021646
Name:LOPEZ, GISELLE (OTA)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5611 W 25TH CT APT 2
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4448
Mailing Address - Country:US
Mailing Address - Phone:786-419-9770
Mailing Address - Fax:305-231-9753
Practice Address - Street 1:12741 SW 17TH CT
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-2500
Practice Address - Country:US
Practice Address - Phone:786-663-0707
Practice Address - Fax:954-447-8844
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-63495106S00000X
FLOTA10840224Z00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLRBT-18-63495OtherREGISTERED BEHAVIOR TECHNICIAN