Provider Demographics
NPI:1891091179
Name:LOPEZ, BLANCA I (PSYD)
Entity Type:Individual
Prefix:DR
First Name:BLANCA
Middle Name:I
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 GOSHEN CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8971
Mailing Address - Country:US
Mailing Address - Phone:787-319-7306
Mailing Address - Fax:
Practice Address - Street 1:3107 EDGEWATER DR STE 1
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-3761
Practice Address - Country:US
Practice Address - Phone:787-319-7306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3898103TC0700X
FL10402103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical