Healthcare Provider Details

I. General information

NPI: 1902089584
Provider Name (Legal Business Name): LORETTA GALLO-LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 DRUID HILLS RD
TEMPLE TERRACE FL
33617-4127
US

IV. Provider business mailing address

5610 N BRANCH AVE
TAMPA FL
33604-7006
US

V. Phone/Fax

Practice location:
  • Phone: 813-355-7684
  • Fax: 813-443-5630
Mailing address:
  • Phone: 813-355-7684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH0002899
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: