MEDICARE: SHARON MAE LOPEZ LSAC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	124038-6006	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	124038-6006	OTHER	UT	UTAH STATE LICENSE

General Provider Information

NPI Number	:	1417252214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHARON MAE LOPEZ LSAC

Provider Business Mailing Address
First Line	:	PO BOX 119
Second Line	:
City	:	AURORA
State	:	UT
Zip	:	84620-0119
Country	:	US
Telephone Number	:	435-896-8236
Fax Number	:

Provider Business Practice Location Address
First Line	:	152 NORTH 400 WEST
Second Line	:
City	:	EPHRIAM
State	:	UT
Zip	:	84627-2131
Country	:	US
Telephone Number	:	435-283-8400
Fax Number	:	435-283-8401

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

Provider Enumeration Date	:	01/26/2011
Last Update Date	:	01/26/2011

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