Provider Demographics
NPI:1538701289
Name:LOPEZ, RAUL ERNESTO
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:ERNESTO
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 1:7175 NW 173RD DR APT 508
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33015-5661
Mailing Address - Country:US
Mailing Address - Phone:786-382-8274
Mailing Address - Fax:
Practice Address - Street 1:7175 NW 173RD DR APT 508
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33015-5661
Practice Address - Country:US
Practice Address - Phone:786-382-8274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician