Provider Demographics
NPI:1679879902
Name:LOPEZ, NATASHA ANN
Entity Type:Individual
Prefix:MRS
First Name:NATASHA
Middle Name:ANN
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 S SPUR
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-2719
Mailing Address - Country:US
Mailing Address - Phone:480-826-1978
Mailing Address - Fax:702-998-2991
Practice Address - Street 1:7565 E EAGLE CREST DR STE 201
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-1067
Practice Address - Country:US
Practice Address - Phone:480-788-5069
Practice Address - Fax:480-634-8850
Is Sole Proprietor?:No
Enumeration Date:2011-02-03
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV01498106H00000X
225400000X
AZLMFT-15540106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1679879902Medicaid