Healthcare Provider Details

I. General information

NPI: 1215874045
Provider Name (Legal Business Name): GIMENA ERMELINDA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2026
Last Update Date: 04/30/2026
Certification Date: 04/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11390 SW 21ST ST
MIRAMAR FL
33025-6633
US

IV. Provider business mailing address

3651 SW 58TH AVE
DAVIE FL
33314-2734
US

V. Phone/Fax

Practice location:
  • Phone: 305-515-5775
  • Fax:
Mailing address:
  • Phone: 786-859-1467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: