Provider Demographics
NPI:1083811368
Name:LOPEZ, SARA ROSE (LMBT)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:ROSE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4811
Mailing Address - Country:US
Mailing Address - Phone:305-490-8956
Mailing Address - Fax:
Practice Address - Street 1:215 WESTERN BLVD STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5730
Practice Address - Country:US
Practice Address - Phone:910-989-0002
Practice Address - Fax:910-375-5381
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6491225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist