Provider Demographics
NPI:1164069456
Name:LOPEZ, JORGE ALBERTO II (MASTERS)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:ALBERTO
Last Name:LOPEZ
Suffix:II
Gender:M
Credentials:MASTERS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14514 SW 167TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-1744
Mailing Address - Country:US
Mailing Address - Phone:786-234-1980
Mailing Address - Fax:
Practice Address - Street 1:2780 SSW 37TH AVE
Practice Address - Street 2:
Practice Address - City:COCONUT GROVE
Practice Address - State:FL
Practice Address - Zip Code:33133
Practice Address - Country:US
Practice Address - Phone:786-234-1980
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18303101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty