=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528428240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRENDA KARINA LOPEZ LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2016
-----------------------------------------------------
Last Update Date | 08/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38040 DAUGHTERY RD
-----------------------------------------------------
City | ZEPHYRHILLS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33540-1375
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-713-6499
-----------------------------------------------------
Fax | 877-544-7007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2766
-----------------------------------------------------
City | ZEPHYRHILLS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33539-2766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-217-1029
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | MS. BRENDA KARINA LOPEZ LLC
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 813-217-1029
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | SW11658
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | SW11658
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | SW11658
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW11658
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------