MEDICARE: MIRTHA 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	RBT-15-07595	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	:	1639521826
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRTHA LOPEZ

Provider Business Mailing Address
First Line	:	113 SW 113TH AVE APT 103
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33174-1178
Country	:	US
Telephone Number	:	786-477-0676
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 SW 113TH AVE APT 103
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33174-1178
Country	:	US
Telephone Number	:	786-477-0676
Fax Number	:

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

Provider Enumeration Date	:	07/12/2016
Last Update Date	:	08/16/2018

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Directions to “ MIRTHA LOPEZ ” Practice Location

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