Healthcare Provider Details

I. General information

NPI: 1619645504
Provider Name (Legal Business Name): LUISETTE M LOPEZ RIVERA PHD, MHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2021
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1176 CYPRESS GLEN CIR
KISSIMMEE FL
34741-7560
US

IV. Provider business mailing address

1905 MORGANS MILL CIR
ORLANDO FL
32825-8296
US

V. Phone/Fax

Practice location:
  • Phone: 352-394-0573
  • Fax:
Mailing address:
  • Phone: 787-310-6149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH26188
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1776
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: