Provider Demographics
NPI:1659885663
Name:LOPEZ, JUAN ANTONIO (MA, LPC)
Entity Type:Individual
Prefix:MR
First Name:JUAN
Middle Name:ANTONIO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 AUGUSTA DR APT 63
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-3715
Mailing Address - Country:US
Mailing Address - Phone:713-539-9740
Mailing Address - Fax:
Practice Address - Street 1:3400 BISSONNET ST STE 280
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-2192
Practice Address - Country:US
Practice Address - Phone:713-539-9740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-29
Last Update Date:2017-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74604101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82-3372401OtherINTERNAL REVENUE SERVICE