Provider Demographics
NPI:1922248160
Name:LOPES, ANA LETICIA GONTIJO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ANA LETICIA
Middle Name:GONTIJO
Last Name:LOPES
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 1:8402 SW 162ND TER
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-3683
Mailing Address - Country:US
Mailing Address - Phone:305-510-6724
Mailing Address - Fax:
Practice Address - Street 1:13430 PARKER COMMONS BLVD
Practice Address - Street 2:101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-1812
Practice Address - Country:US
Practice Address - Phone:239-561-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-28
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 8684103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical