Provider Demographics
NPI:1417740119
Name:LOPEZ, ANA L
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:L
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 W JERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33510-3029
Mailing Address - Country:US
Mailing Address - Phone:402-705-9965
Mailing Address - Fax:
Practice Address - Street 1:13911 N DALE MABRY HWY STE 108
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2414
Practice Address - Country:US
Practice Address - Phone:813-784-3619
Practice Address - Fax:813-305-7033
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-24-383470106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician