Provider Demographics
NPI:1689974909
Name:LOPEZ, ELENA MARIA
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:MARIA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELENA
Other - Middle Name:MARIA
Other - Last Name:GARZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 MAJOR DR
Mailing Address - Street 2:
Mailing Address - City:NORTHLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60164-1822
Mailing Address - Country:US
Mailing Address - Phone:773-297-5843
Mailing Address - Fax:
Practice Address - Street 1:401 MAJOR DR
Practice Address - Street 2:
Practice Address - City:NORTHLAKE
Practice Address - State:IL
Practice Address - Zip Code:60164-1822
Practice Address - Country:US
Practice Address - Phone:773-297-5843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-02
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist