Provider Demographics
NPI:1295467066
Name:LOPEZ, ISLA P
Entity Type:Individual
Prefix:
First Name:ISLA
Middle Name:P
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 1:2020 E EDGEWOOD DR APT 47
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-3644
Mailing Address - Country:US
Mailing Address - Phone:260-249-9231
Mailing Address - Fax:
Practice Address - Street 1:2020 E EDGEWOOD DR APT 47
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-3644
Practice Address - Country:US
Practice Address - Phone:260-249-9231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-18-63186106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9638057033Medicaid