Healthcare Provider Details

I. General information

NPI: 1114513546
Provider Name (Legal Business Name): SOL ANGEL LOPEZ BEHAVIOR TECHNICIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SOL ANGEL PACHECO

II. Dates (important events)

Enumeration Date: 12/20/2020
Last Update Date: 01/09/2021
Certification Date: 01/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 N PARK RD STE 400
HOLLYWOOD FL
33021-6918
US

IV. Provider business mailing address

10820 NW 21ST CT
SUNRISE FL
33322-3412
US

V. Phone/Fax

Practice location:
  • Phone: 954-925-3191
  • Fax: 954-925-3193
Mailing address:
  • Phone: 786-352-7826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: