Healthcare Provider Details

I. General information

NPI: 1912643404
Provider Name (Legal Business Name): GRETEL MARIA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 OAKS WAY APT 904
POMPANO BEACH FL
33069-5387
US

IV. Provider business mailing address

3520 OAKS WAY APT 904
POMPANO BEACH FL
33069-5387
US

V. Phone/Fax

Practice location:
  • Phone: 305-807-1909
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberRBT-20117491
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: