Healthcare Provider Details

I. General information

NPI: 1194107292
Provider Name (Legal Business Name): HEATHER ANN LOPEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2015
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2878 CAMINO DEL RIO S STE 315
SAN DIEGO CA
92108-3846
US

IV. Provider business mailing address

51 W PINE RD
STAATSBURG NY
12580-5405
US

V. Phone/Fax

Practice location:
  • Phone: 619-340-0417
  • Fax:
Mailing address:
  • Phone: 845-206-6834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number092088
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number090466
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number101118
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: