Provider Demographics
NPI:1083182885
Name:LOPEZ, CARLOS G
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:G
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 1:1415 LUMSDEN RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9179
Mailing Address - Country:US
Mailing Address - Phone:360-881-7878
Mailing Address - Fax:360-876-0713
Practice Address - Street 1:1415 LUMSDEN RD
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98367-9179
Practice Address - Country:US
Practice Address - Phone:360-881-7878
Practice Address - Fax:360-876-0713
Is Sole Proprietor?:No
Enumeration Date:2018-11-09
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60613823101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACO60613823OtherWASHINGTON STATE DEPARTMENT OF HEALTH