Healthcare Provider Details

I. General information

NPI: 1962087684
Provider Name (Legal Business Name): CRISTA LOPEZ MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 12/03/2021
Certification Date: 12/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10379B DEMOCRACY LN
FAIRFAX VA
22030-2505
US

IV. Provider business mailing address

25099 CROXLEY GREEN SQ
ALDIE VA
20105-5672
US

V. Phone/Fax

Practice location:
  • Phone: 703-591-2551
  • Fax:
Mailing address:
  • Phone: 571-225-9563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0704013702
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: