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General NPI Number Information
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NPI Number | 1770191223
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Entity Type | Individual
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Provider Name | KORALIS MARY AYALA LOPEZ
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Gender | Female
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Dates
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Enumeration Date | 07/21/2020
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 1728 LILABERRY LN
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City | NICEVILLE
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State | FL
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Zip | 32578-8740
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Country | US
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Telephone | 850-842-9750
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Fax |
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Provider Business Mailing Address
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Address Line | 331 WAVE HL APT 304
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City | MARTINEZ
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State | GA
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Zip | 30907-7349
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Country | US
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Telephone | 706-231-5574
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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 | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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