Provider Demographics
NPI:1619502846
Name:LOPEZ-RODRIGUEZ, LUIS WILFREDO (PLP)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:WILFREDO
Last Name:LOPEZ-RODRIGUEZ
Suffix:
Gender:M
Credentials:PLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 RIVERFRONT BLVD STE 710
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-8812
Mailing Address - Country:US
Mailing Address - Phone:941-776-4000
Mailing Address - Fax:
Practice Address - Street 1:725 N 12TH AVE BLDG B
Practice Address - Street 2:
Practice Address - City:ARCADIA
Practice Address - State:FL
Practice Address - Zip Code:34266-8752
Practice Address - Country:US
Practice Address - Phone:417-761-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020030184103TC0700X
FLPY11347103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical