Provider Demographics
NPI:1518696681
Name:LOPEZ, HEATHER SHAE
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:SHAE
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 1:137 UPLAND WAY # 25
Mailing Address - Street 2:
Mailing Address - City:RESACA
Mailing Address - State:GA
Mailing Address - Zip Code:30735-6186
Mailing Address - Country:US
Mailing Address - Phone:706-229-1742
Mailing Address - Fax:
Practice Address - Street 1:137 UPLAND WAY # 25
Practice Address - Street 2:
Practice Address - City:RESACA
Practice Address - State:GA
Practice Address - Zip Code:30735-6186
Practice Address - Country:US
Practice Address - Phone:706-229-1742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-21-1106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician