Provider Demographics
NPI:1619645504
Name:LOPEZ RIVERA, LUISETTE M (PHD, MHC)
Entity Type:Individual
Prefix:DR
First Name:LUISETTE
Middle Name:M
Last Name:LOPEZ RIVERA
Suffix:
Gender:F
Credentials:PHD, MHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 MORGANS MILL CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-8296
Mailing Address - Country:US
Mailing Address - Phone:787-310-6149
Mailing Address - Fax:
Practice Address - Street 1:1176 CYPRESS GLEN CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7560
Practice Address - Country:US
Practice Address - Phone:352-394-0573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1776101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty