Provider Demographics
NPI:1649582255
Name:LOPEZ-PERGOLESE, CHRISTINE TERESA (CASAC)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:TERESA
Last Name:LOPEZ-PERGOLESE
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MARLBORO RD
Mailing Address - Street 2:
Mailing Address - City:NEW FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06812-3810
Mailing Address - Country:US
Mailing Address - Phone:034-822-4252
Mailing Address - Fax:
Practice Address - Street 1:21 OLD ROUTE 6
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-2107
Practice Address - Country:US
Practice Address - Phone:914-257-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-12
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9568101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03008124Medicaid