Provider Demographics
NPI:1144779844
Name:LOPEZ, MAKENZIE
Entity Type:Individual
Prefix:
First Name:MAKENZIE
Middle Name:
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 1:19806 E 38TH ST S
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-1227
Mailing Address - Country:US
Mailing Address - Phone:539-292-8485
Mailing Address - Fax:
Practice Address - Street 1:2325 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114-3300
Practice Address - Country:US
Practice Address - Phone:918-712-4301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200669990BMedicaid