MEDICARE: MICHELLE MADRUGA 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	106S00000X	Behavior Technician	L120553027200	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	:	1720868375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE MADRUGA LOPEZ

Provider Business Mailing Address
First Line	:	217 SANTA BARBARA ST
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33903-2839
Country	:	US
Telephone Number	:	786-876-2828
Fax Number	:

Provider Business Practice Location Address
First Line	:	217 SANTA BARBARA ST
Second Line	:
City	:	NORTH FORT MYERS
State	:	FL
Zip	:	33903-2839
Country	:	US
Telephone Number	:	786-876-2828
Fax Number	:

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

Provider Enumeration Date	:	10/02/2023
Last Update Date	:	10/02/2023

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Directions to “ MICHELLE MADRUGA LOPEZ ” Practice Location

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