Provider Demographics
NPI:1740054139
Name:SALEM, LOURDES KATY
Entity type:Individual
Prefix:
First Name:LOURDES
Middle Name:KATY
Last Name:SALEM
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 1:4310 W SPRUCE ST UNIT 221
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-4259
Mailing Address - Country:US
Mailing Address - Phone:954-515-6824
Mailing Address - Fax:
Practice Address - Street 1:4310 W SPRUCE ST UNIT 221
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-4259
Practice Address - Country:US
Practice Address - Phone:954-515-6824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-23-302318106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician