Provider Demographics
NPI:1437850823
Name:LOPEZ, SEBASTIAN SERGIO
Entity Type:Individual
Prefix:
First Name:SEBASTIAN
Middle Name:SERGIO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12401 W OKEECHOBEE RD LOT 493
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-2942
Mailing Address - Country:US
Mailing Address - Phone:305-613-8344
Mailing Address - Fax:
Practice Address - Street 1:12401 W OKEECHOBEE RD LOT 493
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-2942
Practice Address - Country:US
Practice Address - Phone:305-613-8344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-261951106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician