Provider Demographics
NPI:1164058756
Name:LOPEZ, IVAN RICARDO (LCSW)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:RICARDO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 LAKE FRONT DR APT B1
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-7171
Mailing Address - Country:US
Mailing Address - Phone:863-216-9151
Mailing Address - Fax:
Practice Address - Street 1:11033 NW STATE ROAD 20
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-6406
Practice Address - Country:US
Practice Address - Phone:850-643-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL168521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical