MEDICARE: LORETTA GALLO-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	101YM0800X	Mental Health Counselor	MH0002899	FL

General Provider Information

NPI Number	:	1902089584
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LORETTA GALLO-LOPEZ

Provider Business Mailing Address
First Line	:	105 E GIDDENS AVE
Second Line	:	SUITE 7
City	:	TAMPA
State	:	FL
Zip	:	33603-2156
Country	:	US
Telephone Number	:	813-231-2520
Fax Number	:	813-200-3293

Provider Business Practice Location Address
First Line	:	105 E GIDDENS AVE
Second Line	:	SUITE 7
City	:	TAMPA
State	:	FL
Zip	:	33603-2156
Country	:	US
Telephone Number	:	813-231-2520
Fax Number	:	813-200-3293

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

Provider Enumeration Date	:	12/06/2007
Last Update Date	:	12/06/2007

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