Provider Demographics
NPI:1134677867
Name:LOPEZ, JOHN R (LMSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 TANWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1934
Mailing Address - Country:US
Mailing Address - Phone:516-608-9931
Mailing Address - Fax:
Practice Address - Street 1:50 W HAWTHORNE AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11580-6220
Practice Address - Country:US
Practice Address - Phone:516-569-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098362-1104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker