Provider Demographics
NPI:1629661079
Name:LIMA LOPEZ, MADELEINI
Entity Type:Individual
Prefix:
First Name:MADELEINI
Middle Name:
Last Name:LIMA LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8373 COUNTRY SQUARE CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-1449
Mailing Address - Country:US
Mailing Address - Phone:786-384-2496
Mailing Address - Fax:
Practice Address - Street 1:4733 W WATERS AVE APT 1137
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-1491
Practice Address - Country:US
Practice Address - Phone:786-384-2496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-17
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-20-138977106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician