Provider Demographics
NPI:1659911279
Name:RODRIGUEZ LOPEZ, MAYLIN
Entity Type:Individual
Prefix:
First Name:MAYLIN
Middle Name:
Last Name:RODRIGUEZ 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 1:5180 W ATLANTIC AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-8103
Mailing Address - Country:US
Mailing Address - Phone:508-328-9147
Mailing Address - Fax:
Practice Address - Street 1:1300 NW 17TH AVE STE 272
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33445-2562
Practice Address - Country:US
Practice Address - Phone:561-865-7084
Practice Address - Fax:561-501-5413
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-11
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-85532106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician