Provider Demographics
NPI:1700540259
Name:LOPEZ GONZALEZ, KENIA C
Entity Type:Individual
Prefix:
First Name:KENIA
Middle Name:C
Last Name:LOPEZ GONZALEZ
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 1:3300 NW 179TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-3418
Mailing Address - Country:US
Mailing Address - Phone:908-220-4918
Mailing Address - Fax:
Practice Address - Street 1:3300 NW 179TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-3418
Practice Address - Country:US
Practice Address - Phone:908-220-4918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty