Provider Demographics
NPI:1669207338
Name:CASTANEDA LOPEZ, JORGE
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:CASTANEDA LOPEZ
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 1:2441 NW 139TH ST
Mailing Address - Street 2:
Mailing Address - City:OPA LOCKA
Mailing Address - State:FL
Mailing Address - Zip Code:33054-4034
Mailing Address - Country:US
Mailing Address - Phone:305-546-6136
Mailing Address - Fax:
Practice Address - Street 1:3990 W FLAGLER ST
Practice Address - Street 2:
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33134-1644
Practice Address - Country:US
Practice Address - Phone:305-392-1143
Practice Address - Fax:786-332-2602
Is Sole Proprietor?:No
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist