Provider Demographics
NPI:1679829790
Name:LOPEZ, MARA (DPT)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 W MARTIN ST
Mailing Address - Street 2:APT 205
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27601-1325
Mailing Address - Country:US
Mailing Address - Phone:786-547-5829
Mailing Address - Fax:
Practice Address - Street 1:10010 FALLS OF NEUSE RD
Practice Address - Street 2:SUITE 015
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8494
Practice Address - Country:US
Practice Address - Phone:919-350-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-26
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT27589225100000X
NCP15894225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist