Provider Demographics
NPI:1558697615
Name:LOPEZ, MARLENE MERCEDES (LPC-LISAC)
Entity Type:Individual
Prefix:MRS
First Name:MARLENE
Middle Name:MERCEDES
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LPC-LISAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 S PEDEN CT
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-7629
Mailing Address - Country:US
Mailing Address - Phone:480-652-4820
Mailing Address - Fax:
Practice Address - Street 1:1324 S PEDEN CT
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-7629
Practice Address - Country:US
Practice Address - Phone:480-652-4820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLISAC10828101YA0400X
AZLPC-13324101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ477673Medicaid