Healthcare Provider Details

I. General information

NPI: 1578184115
Provider Name (Legal Business Name): NATHALIE GUDE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 SW 211TH ST
MIAMI FL
33177-5769
US

IV. Provider business mailing address

12625 SW 211TH ST
MIAMI FL
33177-5769
US

V. Phone/Fax

Practice location:
  • Phone: 786-234-8113
  • Fax:
Mailing address:
  • Phone: 786-234-8113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-116734
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: