Provider Demographics
NPI:1629113030
Name:LOPEZ, BERTHA MARIE (ACSW, LMSW)
Entity Type:Individual
Prefix:MS
First Name:BERTHA
Middle Name:MARIE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:ACSW, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-0009
Mailing Address - Country:US
Mailing Address - Phone:517-264-8086
Mailing Address - Fax:517-264-8086
Practice Address - Street 1:127 S BROAD ST
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2747
Practice Address - Country:US
Practice Address - Phone:517-264-8086
Practice Address - Fax:517-264-8086
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801035506104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7844676Medicare UPIN
0N21480Medicare ID - Type Unspecified
MI9402076Medicare UPIN
MI8008971630Medicare UPIN
MI139865Medicare UPIN