Healthcare Provider Details

I. General information

NPI: 1205633765
Provider Name (Legal Business Name): BRANDON LOPEZ LICSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5480 WISCONSIN AVE STE 204
CHEVY CHASE MD
20815-3524
US

IV. Provider business mailing address

5480 WISCONSIN AVE STE 204
CHEVY CHASE MD
20815-3524
US

V. Phone/Fax

Practice location:
  • Phone: 860-878-9702
  • Fax:
Mailing address:
  • Phone: 860-878-9702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33306
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: