Provider Demographics
NPI:1114236163
Name:LOPEZ, WENDELL MICHAEL (LCSW)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:MICHAEL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8620 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-3702
Mailing Address - Country:US
Mailing Address - Phone:718-256-8818
Mailing Address - Fax:718-234-2314
Practice Address - Street 1:8620 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-3702
Practice Address - Country:US
Practice Address - Phone:718-256-8818
Practice Address - Fax:718-234-2314
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY45282131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical