Provider Demographics
NPI:1902361991
Name:LOPEZ-ESTEVEZ, INDRA LUZ
Entity Type:Individual
Prefix:MRS
First Name:INDRA
Middle Name:LUZ
Last Name:LOPEZ-ESTEVEZ
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 1:3871 ZOEY LEE DR
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-5257
Mailing Address - Country:US
Mailing Address - Phone:845-269-0787
Mailing Address - Fax:
Practice Address - Street 1:5373 THOMPSONS MILL RD
Practice Address - Street 2:
Practice Address - City:HOSCHTON
Practice Address - State:GA
Practice Address - Zip Code:30548-4037
Practice Address - Country:US
Practice Address - Phone:770-967-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001819224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant