Healthcare Provider Details

I. General information

NPI: 1457592255
Provider Name (Legal Business Name): MARTINE T LOPEZ LPCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2009
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

184 UNSER BLVD NE
RIO RANCHO NM
87124-4045
US

IV. Provider business mailing address

2549 TWIN BUTTES DR NE
RIO RANCHO NM
87144-6742
US

V. Phone/Fax

Practice location:
  • Phone: 505-896-0928
  • Fax:
Mailing address:
  • Phone: 505-796-2095
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0129871
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: