Provider Demographics
NPI:1073048252
Name:LOPEZ, JUAN CARLOS
Entity Type:Individual
Prefix:DR
First Name:JUAN
Middle Name:CARLOS
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 EATON DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:PA
Mailing Address - Zip Code:19087-3856
Mailing Address - Country:US
Mailing Address - Phone:610-937-0892
Mailing Address - Fax:
Practice Address - Street 1:103 EATON DR
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:PA
Practice Address - Zip Code:19087-3856
Practice Address - Country:US
Practice Address - Phone:610-937-0892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002750103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst