Healthcare Provider Details

I. General information

NPI: 1497988174
Provider Name (Legal Business Name): ANNIE KATHLEEN LOPEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 CEDAR ST SE STE 4660
ALBUQUERQUE NM
87106-4924
US

IV. Provider business mailing address

PO BOX 26666 PROVIDER ENROLLMENT
ALBUQUERQUE NM
87125-6666
US

V. Phone/Fax

Practice location:
  • Phone: 505-563-6530
  • Fax:
Mailing address:
  • Phone: 505-923-6770
  • Fax: 505-923-5354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11619
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: