Provider Demographics
NPI:1992468011
Name:LOPEZ, ELIZABETH (PSYD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
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 1:1306 SW 6TH TER
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33991-2153
Mailing Address - Country:US
Mailing Address - Phone:786-413-8067
Mailing Address - Fax:
Practice Address - Street 1:4161 TAMIAMI TRL STE 401
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-9254
Practice Address - Country:US
Practice Address - Phone:941-235-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-15
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11246103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist