=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982070629
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LUIS E LOPEZ LCPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2015
-----------------------------------------------------
Last Update Date | 10/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4939 W FULLERTON AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60639-2505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-683-9725
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1815 N 72ND CT
-----------------------------------------------------
City | ELMWOOD PARK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60707-3702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-502-8672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 180.009820
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 180.009820
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------