Provider Demographics
NPI:1609648419
Name:LOPEZ, SANDRA CAROLINA
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:CAROLINA
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 1:324 WASHINGTON AVE APT C3
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-3360
Mailing Address - Country:US
Mailing Address - Phone:929-888-2152
Mailing Address - Fax:
Practice Address - Street 1:63 LEXINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-3627
Practice Address - Country:US
Practice Address - Phone:973-732-8068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-20-40938106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst