Healthcare Provider Details

I. General information

NPI: 1417687690
Provider Name (Legal Business Name): MARIANNE LOPEZ LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2022
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W 35TH ST
CHICAGO IL
60609-1309
US

IV. Provider business mailing address

1130 S CANAL ST # 1291
CHICAGO IL
60607-4907
US

V. Phone/Fax

Practice location:
  • Phone: 312-487-1878
  • Fax:
Mailing address:
  • Phone: 773-230-8438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180.015420
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: