Healthcare Provider Details

I. General information

NPI: 1720116031
Provider Name (Legal Business Name): THERESE LOPEZ, SPEECH-LANGUAGE THERAPY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3061 PAGOSA MEADOWS DR.
RIO RANCHO NM
87144-0534
US

IV. Provider business mailing address

3061 PAGOSA MEADOWS DR NE
RIO RANCHO NM
87144-0534
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0061
  • Fax:
Mailing address:
  • Phone: 505-896-0061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3080
License Number StateNM

VIII. Authorized Official

Name: THERESE ANN LOPEZ
Title or Position: SPEECH-LANGUAGE PATHOLOGIST
Credential: CCC-SLP
Phone: 505-891-5335