Healthcare Provider Details

I. General information

NPI: 1356276406
Provider Name (Legal Business Name): MADELYN N LOPEZ BUENO I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3708 91ST ST STE 3A
JACKSON HEIGHTS NY
11372-7962
US

IV. Provider business mailing address

2196 MATTHEWS AVE APT 4C
BRONX NY
10462-2017
US

V. Phone/Fax

Practice location:
  • Phone: 718-706-1663
  • Fax:
Mailing address:
  • Phone: 917-322-9489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number131570-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: