Provider Demographics
NPI:1346989670
Name:LOPEZ, LISSETTE DEL SOCORRO
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:DEL SOCORRO
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 1:14127 SW 51ST LN
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5976
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14127 SW 51ST LN
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-5976
Practice Address - Country:US
Practice Address - Phone:954-699-7431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22-216954106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician