Provider Demographics
NPI:1891221958
Name:LOPEZ, ANTHONY (ATC)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:TONY
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5750 ABBEY DR
Mailing Address - Street 2:APT 2C
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-2582
Mailing Address - Country:US
Mailing Address - Phone:309-721-6705
Mailing Address - Fax:
Practice Address - Street 1:14011 KENTON AVE
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:IL
Practice Address - Zip Code:60445-2252
Practice Address - Country:US
Practice Address - Phone:219-794-4653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2000026450405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional