Provider Demographics
NPI:1467939165
Name:LOPEZ, LYZA-ANN (BS)
Entity Type:Individual
Prefix:
First Name:LYZA-ANN
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 N GRAPEVINE MILLS BLVD APT 1124
Mailing Address - Street 2:
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-2063
Mailing Address - Country:US
Mailing Address - Phone:432-213-0642
Mailing Address - Fax:
Practice Address - Street 1:9696 SKILLMAN ST STE 220
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-8316
Practice Address - Country:US
Practice Address - Phone:972-591-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1831479344Medicaid