Provider Demographics
NPI:1245558774
Name:LOPEZ, MARY (MA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3297 CHURCHILL DR
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08753-4811
Mailing Address - Country:US
Mailing Address - Phone:732-929-1477
Mailing Address - Fax:
Practice Address - Street 1:39 N. CLINTON AVE
Practice Address - Street 2:CATHOLIC CHARITIES
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08609
Practice Address - Country:US
Practice Address - Phone:609-394-9398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-07
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0018872Medicaid