Provider Demographics
NPI:1669296182
Name:HENRIQUEZ LOPEZ, DIEGO ANDRES
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:ANDRES
Last Name:HENRIQUEZ LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3727 NYACK LN
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-3497
Mailing Address - Country:US
Mailing Address - Phone:561-889-9624
Mailing Address - Fax:
Practice Address - Street 1:3727 NYACK LN
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-3497
Practice Address - Country:US
Practice Address - Phone:561-889-9624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-374122106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician