Provider Demographics
NPI:1689993651
Name:LOPEZ DE VICTORIA, SAMUEL A (LMHC)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:A
Last Name:LOPEZ DE VICTORIA
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12651 S DIXIE HWY
Mailing Address - Street 2:SUITE 327
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33156-5975
Mailing Address - Country:US
Mailing Address - Phone:786-299-7548
Mailing Address - Fax:305-253-3078
Practice Address - Street 1:12651 S DIXIE HWY
Practice Address - Street 2:SUITE 327
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33156-5975
Practice Address - Country:US
Practice Address - Phone:786-299-7548
Practice Address - Fax:305-253-3078
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9101101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health