Provider Demographics
NPI:1215230214
Name:LOPEZ, GINA E (MED)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:E
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 WAGON WHEEL TRL
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34772-8985
Mailing Address - Country:US
Mailing Address - Phone:321-948-9907
Mailing Address - Fax:
Practice Address - Street 1:2905 CONNER LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7723
Practice Address - Country:US
Practice Address - Phone:321-948-9907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator