=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629934666
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILISSA DE JESUS LOPEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2026
-----------------------------------------------------
Last Update Date | 01/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | HC 44 BOX 12949
-----------------------------------------------------
City | CAYEY
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00736-9715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 939-316-5293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | HC 44 BOX 12949
-----------------------------------------------------
City | CAYEY
-----------------------------------------------------
State | PR
-----------------------------------------------------
Zip | 00736-9715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 939-316-5293
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number | 8699
-----------------------------------------------------
License Number State | PR
-----------------------------------------------------