Healthcare Provider Details

I. General information

NPI: 1053815894
Provider Name (Legal Business Name): JAMES LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 10/16/2023
Certification Date: 10/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6121 INDIAN SCHOOL RD NE STE 141
ALBUQUERQUE NM
87110-3176
US

IV. Provider business mailing address

6121 INDIAN SCHOOL RD NE STE 141
ALBUQUERQUE NM
87110-3176
US

V. Phone/Fax

Practice location:
  • Phone: 505-888-1362
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCMH0215081
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: