Healthcare Provider Details

I. General information

NPI: 1457914400
Provider Name (Legal Business Name): SAMANTHA LEE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 PARK PL STE 200H
APPLETON WI
54914-8210
US

IV. Provider business mailing address

N1350 TUCKAWAY CT
GREENVILLE WI
54942-8045
US

V. Phone/Fax

Practice location:
  • Phone: 715-848-5022
  • Fax: 888-778-6750
Mailing address:
  • Phone: 715-301-0014
  • Fax: 888-778-6750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number12932
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: