Provider Demographics
NPI:1750898474
Name:ALFONSO LOPEZ, ESTEBAN (BCABA)
Entity type:Individual
Prefix:MR
First Name:ESTEBAN
Middle Name:
Last Name:ALFONSO LOPEZ
Suffix:
Gender:M
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 NW 71ST AVE APT 501
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33126-4345
Mailing Address - Country:US
Mailing Address - Phone:786-539-8436
Mailing Address - Fax:
Practice Address - Street 1:260 NW 71ST AVE APT 501
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126-4345
Practice Address - Country:US
Practice Address - Phone:786-539-8436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-03
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-21-55132103K00000X
106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103009000Medicaid