Provider Demographics
NPI:1417622317
Name:LOPEZ, SERGIO (LAC)
Entity Type:Individual
Prefix:
First Name:SERGIO
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10925-0464
Mailing Address - Country:US
Mailing Address - Phone:845-537-6908
Mailing Address - Fax:
Practice Address - Street 1:30 FOURTH RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD LAKE
Practice Address - State:NY
Practice Address - Zip Code:10925-2510
Practice Address - Country:US
Practice Address - Phone:845-537-6908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00569600101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
37AC00569600OtherLICENSE NUMBER