MEDICARE: ANGELICA LOPEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558832899
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELICA LOPEZ

Provider Business Mailing Address
First Line	:	481 SE SEAHOUSE DR
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34983-4513
Country	:	US
Telephone Number	:	772-342-1400
Fax Number	:

Provider Business Practice Location Address
First Line	:	590 NW PEACOCK BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-2213
Country	:	US
Telephone Number	:	772-905-8096
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	12/16/2018

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Directions to “ ANGELICA LOPEZ ” Practice Location

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