Provider Demographics
NPI:1821589003
Name:LOPEZ, MARTIN GONZALO (RCSWI)
Entity Type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:GONZALO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:RCSWI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 SW 80TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4931
Mailing Address - Country:US
Mailing Address - Phone:305-878-8268
Mailing Address - Fax:
Practice Address - Street 1:6900 SW 80TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143
Practice Address - Country:US
Practice Address - Phone:786-662-8176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2018-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL154141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical