Provider Demographics
NPI:1225815129
Name:LOPEZ, YESSICA FERNANDA
Entity Type:Individual
Prefix:
First Name:YESSICA
Middle Name:FERNANDA
Last Name:LOPEZ
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 1:260 MILTON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-2927
Mailing Address - Country:US
Mailing Address - Phone:781-344-3400
Mailing Address - Fax:781-326-3400
Practice Address - Street 1:260 MILTON ST STE 101
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-2927
Practice Address - Country:US
Practice Address - Phone:781-344-3400
Practice Address - Fax:781-326-3400
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA415785104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker