Provider Demographics
NPI:1871795559
Name:LOPEZ, MARY BETH (PSYD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:BETH
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3092 NW 127TH TER
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-6343
Mailing Address - Country:US
Mailing Address - Phone:954-533-9019
Mailing Address - Fax:954-530-2054
Practice Address - Street 1:6331 SW 41ST CT
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-3405
Practice Address - Country:US
Practice Address - Phone:954-533-9019
Practice Address - Fax:954-530-2054
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X, 103T00000X, 103TA0700X, 103TC2200X, 103TB0200X, 103TC1900X
FLPY 7941103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling