Healthcare Provider Details

I. General information

NPI: 1285997544
Provider Name (Legal Business Name): PATTY LOPEZ LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 N 1ST ST
GRANTS NM
87020-2806
US

IV. Provider business mailing address

PO BOX 518
LOS LUNAS NM
87031-0518
US

V. Phone/Fax

Practice location:
  • Phone: 505-287-7985
  • Fax: 505-287-3814
Mailing address:
  • Phone: 505-865-3350
  • Fax: 505-865-4739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0134111
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: