Healthcare Provider Details

I. General information

NPI: 1437077435
Provider Name (Legal Business Name): KYLE JOHN LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10823 BOYETTE RD
RIVERVIEW FL
33569-8012
US

IV. Provider business mailing address

10204 COOL WATERLILY AVE
RIVERVIEW FL
33578-4380
US

V. Phone/Fax

Practice location:
  • Phone: 941-243-6355
  • Fax:
Mailing address:
  • Phone: 941-243-6355
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH29488
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: