Healthcare Provider Details

I. General information

NPI: 1770948457
Provider Name (Legal Business Name): LORRAINE TAVAREZ LOPEZ LPES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/22/2015
Last Update Date: 06/08/2024
Certification Date: 06/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 OAKLAND DR
ELGIN SC
29045-9279
US

IV. Provider business mailing address

1057 OAKLAND DR
ELGIN SC
29045-9279
US

V. Phone/Fax

Practice location:
  • Phone: 754-779-0584
  • Fax:
Mailing address:
  • Phone: 754-779-0584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number4657
License Number StateSC
# 4
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number4657
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: