Healthcare Provider Details

I. General information

NPI: 1649403221
Provider Name (Legal Business Name): NATHANIEL LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2009
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 SW 4TH AVE
PORTLAND OR
97204-1813
US

IV. Provider business mailing address

4427 NE 71ST AVE
PORTLAND OR
97218-3547
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-1039
  • Fax:
Mailing address:
  • Phone: 786-337-2326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC10518
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: