=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316283849
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOPEZ PSYCHOLOGICAL SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2013
-----------------------------------------------------
Last Update Date | 04/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 EXECUTIVE PL SUITE B
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28305-5390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-502-0467
-----------------------------------------------------
Fax | 866-707-8680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 87036
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-7036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-502-0467
-----------------------------------------------------
Fax | 866-707-8680
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. KAREN M HERDZIK
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 910-502-0467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 4176
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------