Healthcare Provider Details

I. General information

NPI: 1306393293
Provider Name (Legal Business Name): EVELYN LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2016
Last Update Date: 10/08/2021
Certification Date: 10/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 CENTER ST
MANCHESTER CT
06040-3926
US

IV. Provider business mailing address

2 WATERSIDE XING STE 401
WINDSOR CT
06095-1588
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-3888
  • Fax: 860-645-4132
Mailing address:
  • Phone: 860-731-5522
  • Fax: 860-731-5536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: