Healthcare Provider Details

I. General information

NPI: 1508747767
Provider Name (Legal Business Name): TERESITA LOPEZ ILLARRETA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2025
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 SW 8TH ST STE 258
MIAMI FL
33144-4000
US

IV. Provider business mailing address

2931 SW 1ST AVE
MIAMI FL
33129-2749
US

V. Phone/Fax

Practice location:
  • Phone: 305-810-8869
  • Fax: 305-402-6468
Mailing address:
  • Phone: 786-301-9563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-468375
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: