Provider Demographics
NPI:1659087732
Name:LOPEZ MARTINEZ, IRIANA ELENA
Entity Type:Individual
Prefix:
First Name:IRIANA
Middle Name:ELENA
Last Name:LOPEZ MARTINEZ
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 1:6700 ALLEN ST
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-1808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3175 S CONGRESS AVE STE 203
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33461-2562
Practice Address - Country:US
Practice Address - Phone:561-298-2399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-254571106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician