MEDICARE: MRS. NILSA LOPEZ PSYD

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	103TC0700X	Clinical Psychologist	1300	PR

General Provider Information

NPI Number	:	1629008255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NILSA LOPEZ PSYD

Provider Business Mailing Address
First Line	:	PO BOX 71474
Second Line	:	APS CLINICS OF PR INC
City	:	SAN JUAN
State	:	PR
Zip	:	00936-8574
Country	:	US
Telephone Number	:	787-641-0774
Fax Number	:	787-641-2759

Provider Business Practice Location Address
First Line	:	AVE PONCE DE LEON
Second Line	:	ESQ DEL PARQUE #22
City	:	SAN JUAN
State	:	PR
Zip	:	00913
Country	:	US
Telephone Number	:	787-641-0774
Fax Number	:	787-641-2759

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	07/08/2007

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