=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376398396
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAURA LOPEZ LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2024
-----------------------------------------------------
Last Update Date | 04/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4404 QUEENS BLVD
-----------------------------------------------------
City | LONG ISLAND CITY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11104-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-235-2562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8369 DANIELS ST APT 2
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11435-2108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-235-2562
-----------------------------------------------------
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 | 122554
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------