MEDICARE: MS. MARISSA 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	28524	CA

General Provider Information

NPI Number	:	1205967650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARISSA LOPEZ LCSW

Provider Business Mailing Address
First Line	:	1444 FULTON ST
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93721-1610
Country	:	US
Telephone Number	:	559-860-0821
Fax Number	:	559-206-7199

Provider Business Practice Location Address
First Line	:	1444 FULTON ST
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93721-1610
Country	:	US
Telephone Number	:	559-860-0821
Fax Number	:	559-206-7199

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

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	10/21/2021

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