Provider Demographics
NPI: | 1700010857 |
---|---|
Name: | LOPEZ, BERTHA IRIS (MS,CCC-SLP) |
Entity Type: | Individual |
Prefix: | |
First Name: | BERTHA |
Middle Name: | IRIS |
Last Name: | LOPEZ |
Suffix: | |
Gender: | F |
Credentials: | MS,CCC-SLP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2007 CRESTWOOD PL |
Mailing Address - Street 2: | |
Mailing Address - City: | DENTON |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 76209-2105 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 940-367-8101 |
Mailing Address - Fax: | 940-239-9891 |
Practice Address - Street 1: | 2007 CRESTWOOD PL |
Practice Address - Street 2: | |
Practice Address - City: | DENTON |
Practice Address - State: | TX |
Practice Address - Zip Code: | 76209-2105 |
Practice Address - Country: | US |
Practice Address - Phone: | 940-367-8101 |
Practice Address - Fax: | 940-239-9891 |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2009-05-05 |
Last Update Date: | 2011-06-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 101334 | 235Z00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 235Z00000X | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 201265003 | Medicaid | |
TX | 201265004 | Medicaid | |
TX | 20122650031700010857 | Other | COOK CHILDREN'S HEALTH PLAN/STAR |
TX | LB00802 | Other | COOK CHILDREN'S HEALTH PLAN(CHIP) |