Healthcare Provider Details

I. General information

NPI: 1386204998
Provider Name (Legal Business Name): LAURA GUZMAN LOPEZ LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6536 RIDGE DR
CHICAGO RIDGE IL
60415-1827
US

IV. Provider business mailing address

6536 RIDGE DR
CHICAGO RIDGE IL
60415-1827
US

V. Phone/Fax

Practice location:
  • Phone: 773-391-1416
  • Fax:
Mailing address:
  • Phone: 773-391-1416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180012018
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: