Provider Demographics
NPI:1164667259
Name:LOPEZ, FRED (LCSW)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:
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 1:380 NASSAU RD
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NY
Mailing Address - Zip Code:11575-1343
Mailing Address - Country:US
Mailing Address - Phone:516-546-2975
Mailing Address - Fax:
Practice Address - Street 1:547 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-2605
Practice Address - Country:US
Practice Address - Phone:516-546-2975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-03
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR043649-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical