MEDICARE: YENIS GONZALEZ LOPEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst		FL
2	106S00000X	Behavior Technician		FL
3	103K00000X	Behavior Analyst	1-21-53808	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093203085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YENIS GONZALEZ LOPEZ

Provider Business Mailing Address
First Line	:	12772 NW 102ND PL
Second Line	:
City	:	HIALEAH GARDENS
State	:	FL
Zip	:	33018-6028
Country	:	US
Telephone Number	:	786-398-2965
Fax Number	:

Provider Business Practice Location Address
First Line	:	12772 NW 102ND PL
Second Line	:
City	:	HIALEAH GARDENS
State	:	FL
Zip	:	33018-6028
Country	:	US
Telephone Number	:	786-398-2965
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2018
Last Update Date	:	04/18/2024

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