Provider Demographics
NPI:1932679024
Name:LOPEZ TELLEZ NAVARRETE, LYDA OFELIA
Entity Type:Individual
Prefix:
First Name:LYDA
Middle Name:OFELIA
Last Name:LOPEZ TELLEZ NAVARRETE
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 1:13250 SW 257TH TER
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6818
Mailing Address - Country:US
Mailing Address - Phone:786-451-3904
Mailing Address - Fax:
Practice Address - Street 1:13250 SW 257TH TER
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-6818
Practice Address - Country:US
Practice Address - Phone:786-451-3904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
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
FL024248000Medicaid