Provider Demographics
NPI:1730554510
Name:LOPEZ, TIFFANY LORRAINE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LORRAINE
Last Name:LOPEZ
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 1:17435 US HIGHWAY 441 STE 101
Mailing Address - Street 2:
Mailing Address - City:MOUNT DORA
Mailing Address - State:FL
Mailing Address - Zip Code:32757-6750
Mailing Address - Country:US
Mailing Address - Phone:352-434-0455
Mailing Address - Fax:
Practice Address - Street 1:581 MAIN ST
Practice Address - Street 2:SUITE 640
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-1148
Practice Address - Country:US
Practice Address - Phone:732-204-1635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-05
Last Update Date:2019-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician