Provider Demographics
NPI:1417240607
Name:LOPEZ, MARISELA
Entity Type:Individual
Prefix:MS
First Name:MARISELA
Middle Name:
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 1:4340 KONGA CT
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-1636
Mailing Address - Country:US
Mailing Address - Phone:813-629-0141
Mailing Address - Fax:
Practice Address - Street 1:116 S PINELLAS AVE
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-3632
Practice Address - Country:US
Practice Address - Phone:813-629-0141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL44982225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist