Provider Demographics
NPI:1255719712
Name:LOPEZ, SUSETTE (LCSW)
Entity type:Individual
Prefix:
First Name:SUSETTE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:6652 TANGLEWOOD BAY DR APT 809
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32821-9372
Mailing Address - Country:US
Mailing Address - Phone:239-200-6967
Mailing Address - Fax:
Practice Address - Street 1:6652 TANGLEWOOD BAY DR APT 809
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32821-9372
Practice Address - Country:US
Practice Address - Phone:239-200-6967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2019-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FL151701041C0700X
FLSW151701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNONEMedicaid