Provider Demographics
NPI:1689820656
Name:LOPEZ, CHARMAINE DIANNA
Entity Type:Individual
Prefix:MISS
First Name:CHARMAINE
Middle Name:DIANNA
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 1:601 LOVEJOY RD SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-3849
Mailing Address - Country:US
Mailing Address - Phone:505-440-4018
Mailing Address - Fax:
Practice Address - Street 1:2741 INDIAN SCHOOL RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-2653
Practice Address - Country:US
Practice Address - Phone:505-750-8866
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-11
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NM0166601101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health