Provider Demographics
NPI:1275222002
Name:LOPEZ, SHANNY (RBT)
Entity Type:Individual
Prefix:
First Name:SHANNY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17142 NW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33028-2104
Mailing Address - Country:US
Mailing Address - Phone:201-820-7734
Mailing Address - Fax:786-334-6343
Practice Address - Street 1:6706 NW 72ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33166-3032
Practice Address - Country:US
Practice Address - Phone:786-454-6006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB901488106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician