Provider Demographics
NPI:1407515836
Name:LOPEZ, NATALIE ALYSSA
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:ALYSSA
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 1:9810 SW 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1935
Mailing Address - Country:US
Mailing Address - Phone:786-357-3145
Mailing Address - Fax:
Practice Address - Street 1:9810 SW 3RD ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1935
Practice Address - Country:US
Practice Address - Phone:786-357-3145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-147032106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108871300Medicaid