Provider Demographics
NPI:1376008656
Name:LOPEZ, VANESSA (MA)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 HARDEN BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-1824
Mailing Address - Country:US
Mailing Address - Phone:863-250-4571
Mailing Address - Fax:
Practice Address - Street 1:1818 HARDEN BLVD STE 160
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-1824
Practice Address - Country:US
Practice Address - Phone:863-250-4571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-20-43037103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician