Provider Demographics
NPI:1164021135
Name:BAUTISTA LOPEZ, IRENE (MS, APC, NCC)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:BAUTISTA LOPEZ
Suffix:
Gender:F
Credentials:MS, APC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1727 CHASE COMMON CT
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-3565
Mailing Address - Country:US
Mailing Address - Phone:803-944-1359
Mailing Address - Fax:
Practice Address - Street 1:175 GWINNETT DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8444
Practice Address - Country:US
Practice Address - Phone:678-209-2394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-21
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007617101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health