Healthcare Provider Details

I. General information

NPI: 1942155379
Provider Name (Legal Business Name): JOSE LUIS LOPEZ LSCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2026
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5748 N BROADWAY ST
KANSAS CITY MO
64118-3998
US

IV. Provider business mailing address

5748 N BROADWAY ST
KANSAS CITY MO
64118-3998
US

V. Phone/Fax

Practice location:
  • Phone: 913-213-3645
  • Fax:
Mailing address:
  • Phone: 913-213-3645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number06757
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: