Provider Demographics
NPI:1447723465
Name:ORTEGA LOPEZ, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ORTEGA 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 1:4533 GREAT BLUE HERON DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-6329
Mailing Address - Country:US
Mailing Address - Phone:786-366-9771
Mailing Address - Fax:
Practice Address - Street 1:4533 GREAT BLUE HERON DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-6329
Practice Address - Country:US
Practice Address - Phone:786-366-9771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL18-72887106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019102000Medicaid