Provider Demographics
NPI:1164585303
Name:LOPEZ, ROSITA (MA LLP)
Entity Type:Individual
Prefix:MS
First Name:ROSITA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 RAVENCREST LN
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-5002
Mailing Address - Country:US
Mailing Address - Phone:734-737-1200
Mailing Address - Fax:
Practice Address - Street 1:6223 N CANTON CENTER RD
Practice Address - Street 2:SUITE 210
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2696
Practice Address - Country:US
Practice Address - Phone:734-737-1200
Practice Address - Fax:734-737-1205
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010116104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11543739OtherCAQH