Healthcare Provider Details

I. General information

NPI: 1821903923
Provider Name (Legal Business Name): GEOVANY LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3675 PECOS-MCLEOD INTERCONNECT #100
LAS VEGAS NV
89121
US

IV. Provider business mailing address

8920 PERFECT DIAMOND CT
LAS VEGAS NV
89129-7082
US

V. Phone/Fax

Practice location:
  • Phone: 702-986-9695
  • Fax:
Mailing address:
  • Phone: 323-354-1009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number08350-I
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: