Basic Information
| Provider Information | |||||||||
| NPI: | 1295198364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | LUIS | ||||||||
| MiddleName: | JOSE | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544864005 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1957 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | HOLLYWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330205021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9549212600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2016 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH18482 | FL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 1041C0700X | MH18482 | FL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.