Provider Demographics
NPI:1740961713
Name:LOPEZ, MARTINA BIANCA
Entity type:Individual
Prefix:
First Name:MARTINA
Middle Name:BIANCA
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 1:15280 NW 79TH CT STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-5873
Mailing Address - Country:US
Mailing Address - Phone:305-558-3724
Mailing Address - Fax:786-907-4485
Practice Address - Street 1:9915 NW 41ST ST STE 220
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2445
Practice Address - Country:US
Practice Address - Phone:305-558-3724
Practice Address - Fax:786-907-4485
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11401235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist