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General NPI Number Information
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NPI Number | 1578186219
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Entity Type | Individual
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Provider Name | ROBERTO G LOPEZ-TAMAYO PH.D
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Gender | Male
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Dates
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Enumeration Date | 05/27/2020
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Last Update Date | 07/08/2020
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Provider Practice Location Address
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Address Line | 1747 W ROOSEVELT RD FL 2
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City | CHICAGO
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State | IL
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Zip | 60608-1264
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Country | US
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Telephone | 312-355-0336
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Fax |
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Provider Business Mailing Address
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Address Line | 3035 N HONORE ST
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City | CHICAGO
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State | IL
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Zip | 60657-2007
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Country | US
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Telephone | 847-714-6314
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC2200X
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Taxonomy Name | Clinical Child & Adolescent Psychologist
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License Number | 071.010284
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071.010284
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License Number State | IL
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