Healthcare Provider Details

I. General information

NPI: 1649656315
Provider Name (Legal Business Name): CARLOS LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2015
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DONALD ROSS DR
RALEIGH NC
27610-2593
US

IV. Provider business mailing address

200 E MAIN ST SUITE 201
CLAYTON NC
27520-2472
US

V. Phone/Fax

Practice location:
  • Phone: 919-250-3320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCAS-22117
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberA12129
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: