MEDICARE: BRIAN LOPEZ PHD BCBA

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	103T00000X	Psychologist	0877	NM
2	103K00000X	Behavior Analyst	1-16-22964	NM

General Provider Information

NPI Number	:	1467469429
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN LOPEZ PHD BCBA

Provider Business Mailing Address
First Line	:	8500 WASHINGTON ST NE
Second Line	:	STE A1
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87113-1846
Country	:	US
Telephone Number	:	505-828-3837
Fax Number	:	877-828-1550

Provider Business Practice Location Address
First Line	:	8500 WASHINGTON ST NE
Second Line	:	STE A1
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87113-1846
Country	:	US
Telephone Number	:	505-828-3837
Fax Number	:	877-828-1550

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	10/18/2016

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