Provider Demographics
NPI:1891478467
Name:LOPEZ, WILLOW (LMSW)
Entity Type:Individual
Prefix:
First Name:WILLOW
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LMSW
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 2561
Mailing Address - Street 2:
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-2561
Mailing Address - Country:US
Mailing Address - Phone:575-770-9811
Mailing Address - Fax:
Practice Address - Street 1:405 HUNTER ST
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2656
Practice Address - Country:US
Practice Address - Phone:505-367-3342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-10
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3850361041S0200X
NMM-08290104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool