Provider Demographics
NPI:1265295018
Name:LOPEZ ROJAS, GERARDO L
Entity type:Individual
Prefix:
First Name:GERARDO
Middle Name:L
Last Name:LOPEZ ROJAS
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 1:8013 W 36TH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33018-1629
Mailing Address - Country:US
Mailing Address - Phone:786-760-4371
Mailing Address - Fax:
Practice Address - Street 1:8013 W 36TH AVE APT 3
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33018-1629
Practice Address - Country:US
Practice Address - Phone:786-760-4371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-23-319221106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty