MEDICARE: GLORIA BAUTISTA LOPEZ LPC,LCDC

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	83770	TX
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	15714	TX

General Provider Information

NPI Number	:	1750029773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA BAUTISTA LOPEZ LPC,LCDC

Provider Business Mailing Address
First Line	:	9501 N FM 620 RD APT 4502
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78726-2906
Country	:	US
Telephone Number	:	512-944-7630
Fax Number	:

Provider Business Practice Location Address
First Line	:	9501 N FM 620 RD APT 4502
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78726-2906
Country	:	US
Telephone Number	:	512-944-7630
Fax Number	:

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

Provider Enumeration Date	:	05/20/2022
Last Update Date	:	07/24/2024

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