Healthcare Provider Details

I. General information

NPI: 1700480654
Provider Name (Legal Business Name): LIBNY LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2020
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4418 5TH ST W
BRADENTON FL
34207-1531
US

IV. Provider business mailing address

4418 5TH ST W
BRADENTON FL
34207-1531
US

V. Phone/Fax

Practice location:
  • Phone: 727-492-5369
  • Fax:
Mailing address:
  • Phone: 727-492-5369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-25-85864
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: