Provider Demographics
NPI:1275776064
Name:LOPEZ, INGRID VIRGINIA
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:VIRGINIA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BAYVIEW DR APT 1821
Mailing Address - Street 2:
Mailing Address - City:SUNNY ISLES BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33160-4779
Mailing Address - Country:US
Mailing Address - Phone:786-709-8397
Mailing Address - Fax:
Practice Address - Street 1:7575 W FLAGLER ST STE 200
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33144-2467
Practice Address - Country:US
Practice Address - Phone:305-377-3297
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-15-06679106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician