MEDICARE: DR. ANA MERCEDES LOPEZ PHD PSYD

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	103TC0700X	Clinical Psychologist	763	IA

General Provider Information

NPI Number	:	1790993962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANA MERCEDES LOPEZ PHD PSYD

Provider Business Mailing Address
First Line	:	1038 DECATUR RD
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28540-6829
Country	:	US
Telephone Number	:	515-802-2487
Fax Number	:	800-426-3978

Provider Business Practice Location Address
First Line	:	209 N 35TH ST
Second Line	:
City	:	MOREHEAD CITY
State	:	NC
Zip	:	28557-3183
Country	:	US
Telephone Number	:	515-802-2487
Fax Number	:

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

Provider Enumeration Date	:	05/19/2007
Last Update Date	:	12/09/2019

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