Provider Demographics
NPI:1164642880
Name:LOPEZ, EVELYN (ITDS-PROVIDER)
Entity Type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:ITDS-PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19634 BLACK OLIVE LN
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33498-4828
Mailing Address - Country:US
Mailing Address - Phone:561-477-5832
Mailing Address - Fax:
Practice Address - Street 1:19634 BLACK OLIVE LN
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33498-4828
Practice Address - Country:US
Practice Address - Phone:561-477-5832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2018-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL811788800Medicaid