Healthcare Provider Details

I. General information

NPI: 1932676806
Provider Name (Legal Business Name): CHRYSTAL VERGARA-LOPEZ PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2018
Last Update Date: 09/02/2025
Certification Date: 09/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 WAMPANOAG TRL
RIVERSIDE RI
02915-2232
US

IV. Provider business mailing address

DEPT 3010, PO BOX 986524
BOSTON MA
02298-6524
US

V. Phone/Fax

Practice location:
  • Phone: 401-649-4050
  • Fax: 401-649-4051
Mailing address:
  • Phone: 401-443-4992
  • Fax: 401-784-4913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS01743
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: