Healthcare Provider Details

I. General information

NPI: 1336978600
Provider Name (Legal Business Name): WILMARIE CRUZ LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 NORWOOD DRIVE
DELTONA FL
32725-7215
US

IV. Provider business mailing address

7108 SOUTH KANNER HWY
STUART FL
34997-7462
US

V. Phone/Fax

Practice location:
  • Phone: 407-417-9907
  • Fax:
Mailing address:
  • Phone: 855-832-6727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-364418
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: