Provider Demographics
NPI:1790118123
Name:LOPEZ, MARILYN
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
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:PO BOX 101
Mailing Address - Street 2:
Mailing Address - City:LAS PIEDRAS
Mailing Address - State:PR
Mailing Address - Zip Code:00771-0101
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 CALLE GAUTIER BENITEZ
Practice Address - Street 2:CONSOLIDATE MALL SUITE C-21
Practice Address - City:CAGUAS
Practice Address - State:PR
Practice Address - Zip Code:00725-5527
Practice Address - Country:US
Practice Address - Phone:787-653-4001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-21
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR005213103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist