Provider Demographics
NPI:1861209173
Name:LOPEZ RODRIGUEZ, KENNETH (MS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:LOPEZ RODRIGUEZ
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:
Other - Last Name:LOPEZ RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS
Mailing Address - Street 1:BO CARMELITA
Mailing Address - Street 2:BUZON 12 CALLE 9
Mailing Address - City:VEGA BAJA
Mailing Address - State:PR
Mailing Address - Zip Code:00693-3714
Mailing Address - Country:US
Mailing Address - Phone:787-224-1736
Mailing Address - Fax:
Practice Address - Street 1:BO CARMELITA
Practice Address - Street 2:BUZON 12 CALLE 9
Practice Address - City:VEGA BAJA
Practice Address - State:PR
Practice Address - Zip Code:00693-3714
Practice Address - Country:US
Practice Address - Phone:787-224-1736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR6502103TF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0000XBehavioral Health & Social Service ProvidersPsychologistFamily