Healthcare Provider Details

I. General information

NPI: 1700981412
Provider Name (Legal Business Name): MARIANNE REDMOND LOPEZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 AMOS LN
FREDERICKSBURG VA
22407-7107
US

IV. Provider business mailing address

43 TOWN AND COUNTRY DR SUITE #143
FREDERICKSBURG VA
22405-8729
US

V. Phone/Fax

Practice location:
  • Phone: 703-862-5679
  • Fax:
Mailing address:
  • Phone: 703-862-5679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0904004604
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: