Provider Demographics
NPI:1245705813
Name:LOPEZ FERNANDEZ, ARIEL
Entity type:Individual
Prefix:
First Name:ARIEL
Middle Name:
Last Name:LOPEZ FERNANDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9401 SW 4TH ST APT 404
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-2035
Mailing Address - Country:US
Mailing Address - Phone:786-479-2016
Mailing Address - Fax:
Practice Address - Street 1:11890 SW 8TH ST STE 309
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33184-1710
Practice Address - Country:US
Practice Address - Phone:305-220-6060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-09
Last Update Date:2018-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-57055106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022777700Medicaid