Provider Demographics
NPI:1093422453
Name:LOPEZ, MARISSA ARIANA
Entity Type:Individual
Prefix:
First Name:MARISSA
Middle Name:ARIANA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 S MASSASOIT AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-3728
Mailing Address - Country:US
Mailing Address - Phone:773-895-0433
Mailing Address - Fax:
Practice Address - Street 1:14933 FOUNDERS XING
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-6712
Practice Address - Country:US
Practice Address - Phone:773-895-0433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178018222101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional