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General NPI Number Information
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NPI Number | 1619502846
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Entity Type | Individual
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Provider Name | LUIS WILFREDO LOPEZ-RODRIGUEZ PLP
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Gender | Male
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Dates
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Enumeration Date | 03/09/2020
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Last Update Date | 02/17/2023
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Provider Practice Location Address
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Address Line | 725 N 12TH AVE BLDG B
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City | ARCADIA
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State | FL
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Zip | 34266-8752
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Country | US
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Telephone | 417-761-5000
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Fax |
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Provider Business Mailing Address
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Address Line | 101 RIVERFRONT BLVD STE 710
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City | BRADENTON
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State | FL
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Zip | 34205-8812
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Country | US
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Telephone | 941-776-4000
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 2020030184
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY11347
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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