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
StateLicense IDTaxonomies
TX101334235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX201265003Medicaid
TX201265004Medicaid
TX20122650031700010857OtherCOOK CHILDREN'S HEALTH PLAN/STAR
TXLB00802OtherCOOK CHILDREN'S HEALTH PLAN(CHIP)