Provider Demographics
NPI:1770250110
Name:LOPEZ, KIMBERLY ESTEPHANIA
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ESTEPHANIA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15667 W HAMMOND DR
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-3213
Mailing Address - Country:US
Mailing Address - Phone:602-451-6772
Mailing Address - Fax:
Practice Address - Street 1:401 W VAN BUREN ST STE C
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1306
Practice Address - Country:US
Practice Address - Phone:623-505-6307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA13320235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist