MEDICARE: AMY LEIGH LOPEZ LSW

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	104100000X	Social Worker	33005170A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1811910466	OTHER	IN	LSW

General Provider Information

NPI Number	:	1811910466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY LEIGH LOPEZ LSW

Provider Business Mailing Address
First Line	:	515 BAYOU ST
Second Line	:
City	:	VINCENNES
State	:	IN
Zip	:	47591-1034
Country	:	US
Telephone Number	:	812-886-6800
Fax Number	:	812-886-6809

Provider Business Practice Location Address
First Line	:	2007 STATE ST
Second Line	:
City	:	WASHINGTON
State	:	IN
Zip	:	47501-8505
Country	:	US
Telephone Number	:	812-254-1558
Fax Number	:	812-254-8308

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	07/08/2007

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