Provider Demographics
NPI:1700650678
Name:LOPEZ, GRACIA MARIA
Entity Type:Individual
Prefix:
First Name:GRACIA
Middle Name:MARIA
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 1:13455 NE 10TH AVE APT 303
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-4146
Mailing Address - Country:US
Mailing Address - Phone:954-279-4978
Mailing Address - Fax:
Practice Address - Street 1:701 PROMENADE DR STE 250
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-6035
Practice Address - Country:US
Practice Address - Phone:954-279-4978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst