Provider Demographics
NPI:1669957403
Name:LOPEZ, DAYLIN
Entity type:Individual
Prefix:
First Name:DAYLIN
Middle Name:
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 1:11531 SW 142ND PL
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-7008
Mailing Address - Country:US
Mailing Address - Phone:305-733-7088
Mailing Address - Fax:305-675-5987
Practice Address - Street 1:11531 SW 142 ND PL
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-3318
Practice Address - Country:US
Practice Address - Phone:305-733-7088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL023131600106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023131600Medicaid