Provider Demographics
NPI:1225727548
Name:LOPEZ, JUAN CARLOS (LMSW)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 FAIRWAY CT
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-2760
Mailing Address - Country:US
Mailing Address - Phone:860-478-2928
Mailing Address - Fax:
Practice Address - Street 1:35 FAIRWAY CT
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-2760
Practice Address - Country:US
Practice Address - Phone:860-478-2928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7056104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker