Healthcare Provider Details

I. General information

NPI: 1982070629
Provider Name (Legal Business Name): LUIS E LOPEZ LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4939 W FULLERTON AVE
CHICAGO IL
60639-2505
US

IV. Provider business mailing address

1815 N 72ND CT
ELMWOOD PARK IL
60707-3702
US

V. Phone/Fax

Practice location:
  • Phone: 708-683-9725
  • Fax:
Mailing address:
  • Phone: 616-502-8672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.009820
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.009820
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: