Provider Demographics
NPI:1316570146
Name:LOPEZ, LAURENCE LOPEZ
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:LOPEZ
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 5TH AVE N APT 424
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-2878
Mailing Address - Country:US
Mailing Address - Phone:719-217-2212
Mailing Address - Fax:
Practice Address - Street 1:2400 WHITE AVE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37204-2235
Practice Address - Country:US
Practice Address - Phone:615-460-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-20
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1924106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist