Healthcare Provider Details

I. General information

NPI: 1174489082
Provider Name (Legal Business Name): MICHELLE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E WASHINGTON ST
ASHKUM IL
60911-7094
US

IV. Provider business mailing address

309 E WASHINGTON ST
ASHKUM IL
60911-7094
US

V. Phone/Fax

Practice location:
  • Phone: 773-915-3379
  • Fax:
Mailing address:
  • Phone: 773-915-3379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: