MEDICARE: MANDY LOPEZ LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	C-09467	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13583510	OTHER	NM	CA QH#
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053735100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANDY LOPEZ LCSW

Provider Business Mailing Address
First Line	:	2710 BLUE MOON DR NE
Second Line	:
City	:	RIO RANCHO
State	:	NM
Zip	:	87144-4145
Country	:	US
Telephone Number	:	505-901-0120
Fax Number	:

Provider Business Practice Location Address
First Line	:	6330 RIVERSIDE PLAZA LN NW STE 260
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-2160
Country	:	US
Telephone Number	:	505-226-2839
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2014
Last Update Date	:	01/31/2019

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Directions to “ MANDY LOPEZ LCSW” Practice Location

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