Provider Demographics
NPI:1437694940
Name:LOPEZ, MARTHA LORENA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:LORENA
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 1:17336 NW 62ND PL
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-4501
Mailing Address - Country:US
Mailing Address - Phone:786-712-1967
Mailing Address - Fax:
Practice Address - Street 1:17336 NW 62ND PL
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-4501
Practice Address - Country:US
Practice Address - Phone:786-712-1967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA27201208100000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation