Provider Demographics
NPI:1164672333
Name:LOPEZ - DIAZ, IDALIA
Entity Type:Individual
Prefix:MS
First Name:IDALIA
Middle Name:
Last Name:LOPEZ - DIAZ
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 1:161 HALSTON PKWY
Mailing Address - Street 2:
Mailing Address - City:EAST AMHERST
Mailing Address - State:NY
Mailing Address - Zip Code:14051-1891
Mailing Address - Country:US
Mailing Address - Phone:716-689-3846
Mailing Address - Fax:
Practice Address - Street 1:161 HALSTON PKWY
Practice Address - Street 2:
Practice Address - City:EAST AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14051-1891
Practice Address - Country:US
Practice Address - Phone:716-689-3846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-24
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017446235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist