Healthcare Provider Details

I. General information

NPI: 1962165530
Provider Name (Legal Business Name): SOFIA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2021
Last Update Date: 10/20/2021
Certification Date: 10/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 ALLEGHANY ST
ROXBURY MA
02120-3338
US

IV. Provider business mailing address

1959 COMMONWEALTH AVE
BOSTON MA
02135-5924
US

V. Phone/Fax

Practice location:
  • Phone: 617-254-0964
  • Fax:
Mailing address:
  • Phone: 914-265-0265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: