Provider Demographics
NPI:1578916045
Name:LOPEZ, MIRIAM L (MPSY)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:L
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MPSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:HC 74 BOX 6869
Mailing Address - Street 2:
Mailing Address - City:CAYEY
Mailing Address - State:PR
Mailing Address - Zip Code:00736-9539
Mailing Address - Country:US
Mailing Address - Phone:939-325-3257
Mailing Address - Fax:
Practice Address - Street 1:HC 74 BOX 6869
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736-9539
Practice Address - Country:US
Practice Address - Phone:939-325-3257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR5685103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling