Healthcare Provider Details

I. General information

NPI: 1447108006
Provider Name (Legal Business Name): ROCIO LOPEZ BA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

433 PARK ST
HAZELTON ID
83335
US

IV. Provider business mailing address

PO BOX 404
HAZELTON ID
83335-0404
US

V. Phone/Fax

Practice location:
  • Phone: 208-490-1410
  • Fax:
Mailing address:
  • Phone: 208-490-1410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License NumberVG478686E
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: