Provider Demographics
NPI:1922638238
Name:PEREZ LOPEZ, LOURDES ISVELL
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:ISVELL
Last Name:PEREZ 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 1:320 SE 11TH AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-7409
Mailing Address - Country:US
Mailing Address - Phone:954-242-0842
Mailing Address - Fax:
Practice Address - Street 1:320 SE 11TH AVE APT 310
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-7409
Practice Address - Country:US
Practice Address - Phone:954-242-0842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-26
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103130700Medicaid