Provider Demographics
NPI:1720868375
Name:LOPEZ, MICHELLE MADRUGA
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MADRUGA
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 1:217 SANTA BARBARA ST
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-2839
Mailing Address - Country:US
Mailing Address - Phone:786-876-2828
Mailing Address - Fax:
Practice Address - Street 1:217 SANTA BARBARA ST
Practice Address - Street 2:
Practice Address - City:NORTH FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33903-2839
Practice Address - Country:US
Practice Address - Phone:786-876-2828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL120553027200106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician