Provider Demographics
NPI:1467043786
Name:LOPEZ, AHISSA
Entity Type:Individual
Prefix:
First Name:AHISSA
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 1:27672 N HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:ISLAND LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60042-8457
Mailing Address - Country:US
Mailing Address - Phone:847-890-8011
Mailing Address - Fax:
Practice Address - Street 1:990 CORPORATE WOODS PKWY
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-3155
Practice Address - Country:US
Practice Address - Phone:224-513-6448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst