MEDICARE: MR. GABRIEL MANUEL LOPEZ JR. LMSW

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	101YM0800X	Mental Health Counselor	LMSW-17543	AZ

General Provider Information

NPI Number	:	1265080196
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GABRIEL MANUEL LOPEZ JR. LMSW

Provider Business Mailing Address
First Line	:	4560 E BROADWAY BLVD STE 223
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-3558
Country	:	US
Telephone Number	:	502-850-1114
Fax Number	:

Provider Business Practice Location Address
First Line	:	4560 E BROADWAY BLVD STE 223
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85711-3558
Country	:	US
Telephone Number	:	520-850-1114
Fax Number	:

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

Provider Enumeration Date	:	09/04/2019
Last Update Date	:	09/04/2019

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