Provider Demographics
NPI:1619606787
Name:LOPEZ, XAMARA NICOLE (RBT)
Entity Type:Individual
Prefix:
First Name:XAMARA
Middle Name:NICOLE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19620 STERLING DR
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-8556
Mailing Address - Country:US
Mailing Address - Phone:786-797-1457
Mailing Address - Fax:
Practice Address - Street 1:93911 OVERSEAS HWY STE 8
Practice Address - Street 2:
Practice Address - City:TAVERNIER
Practice Address - State:FL
Practice Address - Zip Code:33070-3025
Practice Address - Country:US
Practice Address - Phone:786-387-0746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL114129700Medicaid