Healthcare Provider Details

I. General information

NPI: 1508638982
Provider Name (Legal Business Name): ELIZABETH BRISENO LOPEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2023
Last Update Date: 10/27/2023
Certification Date: 10/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 E ROOSEVELT ST
PHOENIX AZ
85008-4948
US

IV. Provider business mailing address

2525 E ROOSEVELT ST
PHOENIX AZ
85008-4948
US

V. Phone/Fax

Practice location:
  • Phone: 602-344-1015
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-21593
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: