MEDICARE: LEI LOPEZ LAVARIAS 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	PY0458	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871695775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEI LOPEZ LAVARIAS PSYD

Provider Business Mailing Address
First Line	:	6170 W LAKE MEAD BLVD
Second Line	:	#294
City	:	LAS VEGAS
State	:	NV
Zip	:	89108
Country	:	US
Telephone Number	:	702-303-2503
Fax Number	:

Provider Business Practice Location Address
First Line	:	6170 W LAKE MEAD BLVD
Second Line	:	#294
City	:	LAS VEGAS
State	:	NV
Zip	:	89108
Country	:	US
Telephone Number	:	702-303-2503
Fax Number	:

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

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	07/08/2007

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