Provider Demographics
NPI:1689048258
Name:LOPEZ, ELIAS SAMUEL (MSW)
Entity Type:Individual
Prefix:
First Name:ELIAS
Middle Name:SAMUEL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3382
Mailing Address - Street 2:
Mailing Address - City:RIO GRANDE
Mailing Address - State:PR
Mailing Address - Zip Code:00745-3382
Mailing Address - Country:US
Mailing Address - Phone:787-988-5349
Mailing Address - Fax:
Practice Address - Street 1:704 CALLE MONSERRATE
Practice Address - Street 2:
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00907-4511
Practice Address - Country:US
Practice Address - Phone:787-724-4051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR12849104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker