Provider Demographics
NPI:1265690473
Name:LOPEZ, SANDRA (BS)
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11031 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-7182
Mailing Address - Country:US
Mailing Address - Phone:305-398-6100
Mailing Address - Fax:305-757-4465
Practice Address - Street 1:4215 SW 72ND AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-4510
Practice Address - Country:US
Practice Address - Phone:305-377-3297
Practice Address - Fax:305-377-3854
Is Sole Proprietor?:No
Enumeration Date:2008-05-26
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
FLCBHCMS100001171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker