Provider Demographics
NPI:1346763695
Name:LOPEZ FUSTES, REBECA
Entity Type:Individual
Prefix:
First Name:REBECA
Middle Name:
Last Name:LOPEZ FUSTES
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 1:6361 COW PEN RD APT T212
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33014-2208
Mailing Address - Country:US
Mailing Address - Phone:305-321-2342
Mailing Address - Fax:305-742-2190
Practice Address - Street 1:6361 COW PEN RD APT T212
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2208
Practice Address - Country:US
Practice Address - Phone:305-321-2342
Practice Address - Fax:305-742-2190
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst