Provider Demographics
NPI:1790019545
Name:LOPEZ, JOSE JULIAN (LSAA)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:JULIAN
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LSAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 520
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532
Mailing Address - Country:US
Mailing Address - Phone:505-852-2580
Mailing Address - Fax:505-852-1827
Practice Address - Street 1:COUNTY ROAD 41 PVT DRIVE 1098
Practice Address - Street 2:
Practice Address - City:VELARDE
Practice Address - State:NM
Practice Address - Zip Code:87582
Practice Address - Country:US
Practice Address - Phone:505-852-2580
Practice Address - Fax:505-852-1827
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0064231101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)