MEDICARE: LAURA GUZMAN LOPEZ LCPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180012018	IL

General Provider Information

NPI Number	:	1386204998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA GUZMAN LOPEZ LCPC

Provider Business Mailing Address
First Line	:	6536 RIDGE DR
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-1827
Country	:	US
Telephone Number	:	773-391-1416
Fax Number	:

Provider Business Practice Location Address
First Line	:	6536 RIDGE DR
Second Line	:
City	:	CHICAGO RIDGE
State	:	IL
Zip	:	60415-1827
Country	:	US
Telephone Number	:	773-391-1416
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/17/2019
Last Update Date	:	06/17/2019

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