Provider Demographics
NPI:1760050272
Name:LOPES, THALES DEIVES (PMHNP)
Entity Type:Individual
Prefix:
First Name:THALES
Middle Name:DEIVES
Last Name:LOPES
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15012 GEORGIA AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20853-1848
Mailing Address - Country:US
Mailing Address - Phone:240-389-8213
Mailing Address - Fax:
Practice Address - Street 1:USAG HUMPHREYS JENKINS MEDICAL CLINIC BLDG 3030
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96271
Practice Address - Country:US
Practice Address - Phone:315-737-1411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-12
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1129516363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health