Provider Demographics
NPI:1730547746
Name:LOPEZ BLANCO, MAYELIN
Entity type:Individual
Prefix:
First Name:MAYELIN
Middle Name:
Last Name:LOPEZ BLANCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13255 NW 4TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33182-1625
Mailing Address - Country:US
Mailing Address - Phone:786-389-8846
Mailing Address - Fax:
Practice Address - Street 1:13255 NW 4TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33182-1625
Practice Address - Country:US
Practice Address - Phone:786-389-8846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT1508771106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician