Provider Demographics
NPI:1497531479
Name:LOPEZ FORTE, ERNESTO (BACB935030)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:LOPEZ FORTE
Suffix:
Gender:M
Credentials:BACB935030
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5929 COLCHESTER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-1617
Mailing Address - Country:US
Mailing Address - Phone:754-273-4828
Mailing Address - Fax:
Practice Address - Street 1:5929 COLCHESTER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812-1617
Practice Address - Country:US
Practice Address - Phone:754-273-4828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-296297106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician