Provider Demographics
NPI:1417572603
Name:LOPEZ-CORBIN, MIXI
Entity Type:Individual
Prefix:
First Name:MIXI
Middle Name:
Last Name:LOPEZ-CORBIN
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 1:1500 SHERMAN AVE APT 419
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4439
Mailing Address - Country:US
Mailing Address - Phone:571-278-5097
Mailing Address - Fax:
Practice Address - Street 1:6501 S PROMONTORY DR
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60649-1003
Practice Address - Country:US
Practice Address - Phone:800-770-2232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA122589-SW-LICSW1041C0700X
IL149.0223681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical