Provider Demographics
NPI:1750851408
Name:LOPEZ, AMBER GENTRY (MED, LPC, CHST, RPT)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:GENTRY
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MED, LPC, CHST, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 SUMMER TREE CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGTOWN
Mailing Address - State:TX
Mailing Address - Zip Code:76082-2267
Mailing Address - Country:US
Mailing Address - Phone:817-946-9863
Mailing Address - Fax:
Practice Address - Street 1:505 SUMMER TREE CT
Practice Address - Street 2:
Practice Address - City:SPRINGTOWN
Practice Address - State:TX
Practice Address - Zip Code:76082-2267
Practice Address - Country:US
Practice Address - Phone:817-946-9863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2021-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74793101YP2500X
TX101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool