Healthcare Provider Details

I. General information

NPI: 1811297997
Provider Name (Legal Business Name): MARIA IVETTE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2010
Last Update Date: 10/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 CALLE FERNANDEZ GARCIA SUITE 66 D
LUQUILLO PR
00773-2215
US

IV. Provider business mailing address

PO BOX 1477
LUQUILLO PR
00773-1477
US

V. Phone/Fax

Practice location:
  • Phone: 787-616-8057
  • Fax:
Mailing address:
  • Phone: 787-616-8057
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number3578
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number5942
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: