=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306621594
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELICA LIZETH LOPEZ LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2023
-----------------------------------------------------
Last Update Date | 08/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 483 W SEED FARM RD
-----------------------------------------------------
City | SACATON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85147-5000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-562-1200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 250 S ELIZABETH WAY APT 1100
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85225-9441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-988-1004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | LMSW-19906
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------