Provider Demographics
NPI:1679654347
Name:LOPEZ, JOHNNY (LCSW)
Entity Type:Individual
Prefix:MR
First Name:JOHNNY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 FORT LEE RD
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-1115
Mailing Address - Country:US
Mailing Address - Phone:212-305-7694
Mailing Address - Fax:212-342-5703
Practice Address - Street 1:57 SAINT MARKS PL
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-7902
Practice Address - Country:US
Practice Address - Phone:212-982-3470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY070236-71041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical