Provider Demographics
NPI:1669034377
Name:LOPEZ, JUAN MOISES (MED)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MOISES
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MED
Other - Prefix:MR
Other - First Name:JUAN
Other - Middle Name:MOISES
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:JUAN M LOPEZ
Mailing Address - Street 1:615 E ROGERS RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78541-8264
Mailing Address - Country:US
Mailing Address - Phone:956-624-9158
Mailing Address - Fax:
Practice Address - Street 1:615 E ROGERS RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78541-8264
Practice Address - Country:US
Practice Address - Phone:956-624-9158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX17301101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional