Healthcare Provider Details

I. General information

NPI: 1679654347
Provider Name (Legal Business Name): JOHNNY LOPEZ LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 SAINT MARKS PL
NEW YORK NY
10003-7902
US

IV. Provider business mailing address

454 FORT LEE RD
LEONIA NJ
07605-1115
US

V. Phone/Fax

Practice location:
  • Phone: 212-982-3470
  • Fax:
Mailing address:
  • Phone: 212-305-7694
  • Fax: 212-342-5703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number070236-7
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: