Provider Demographics
NPI:1104370238
Name:LOPEZ, TERESA MARIE
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
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 1:3360 N HIGHWAY 59 STE K
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-9405
Mailing Address - Country:US
Mailing Address - Phone:209-726-3090
Mailing Address - Fax:
Practice Address - Street 1:515 28 3/4 RD
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-5016
Practice Address - Country:US
Practice Address - Phone:970-241-6023
Practice Address - Fax:970-242-8330
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-05
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program