Provider Demographics
NPI:1235436825
Name:LOPEZ, MARCOS M (MA)
Entity Type:Individual
Prefix:
First Name:MARCOS
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 CALLE GEORGETTI
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00925-3607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:66 CALLE GEORGETTI
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925-3607
Practice Address - Country:US
Practice Address - Phone:787-528-5605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-17
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR3896103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist