Healthcare Provider Details

I. General information

NPI: 1144244328
Provider Name (Legal Business Name): JUAN J LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MAUD ST
TAVARES FL
32778-3249
US

IV. Provider business mailing address

101 E MAUD ST
TAVARES FL
32778-3249
US

V. Phone/Fax

Practice location:
  • Phone: 352-253-9348
  • Fax: 352-253-9351
Mailing address:
  • Phone: 352-253-9348
  • Fax: 352-253-9351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS648
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: