Provider Demographics
NPI:1417694233
Name:LOPEZ, CHALYSE
Entity Type:Individual
Prefix:
First Name:CHALYSE
Middle Name:
Last Name:LOPEZ
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 1:434 N 250 W
Mailing Address - Street 2:
Mailing Address - City:LA VERKIN
Mailing Address - State:UT
Mailing Address - Zip Code:84745-5202
Mailing Address - Country:US
Mailing Address - Phone:435-691-0843
Mailing Address - Fax:
Practice Address - Street 1:1611 E 2450 S STE 5A
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-6285
Practice Address - Country:US
Practice Address - Phone:435-767-1011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-13
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
12317059-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health