Provider Demographics
NPI:1053967893
Name:LOPEZ, LARYSSA CHARISSE (RBT)
Entity type:Individual
Prefix:
First Name:LARYSSA
Middle Name:CHARISSE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 E NASA BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1900
Mailing Address - Country:US
Mailing Address - Phone:321-372-6813
Mailing Address - Fax:321-765-6434
Practice Address - Street 1:125 E NASA BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1900
Practice Address - Country:US
Practice Address - Phone:321-372-6813
Practice Address - Fax:321-765-6434
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-16
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-95786106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician