Provider Demographics
NPI:1932120730
Name:PEREZ-LOPEZ, MARK S (PH D LCP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:S
Last Name:PEREZ-LOPEZ
Suffix:
Gender:M
Credentials:PH D LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PROFESSIONAL PARK DR SE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-6679
Mailing Address - Country:US
Mailing Address - Phone:540-951-4800
Mailing Address - Fax:540-951-3081
Practice Address - Street 1:200 PROFESSIONAL PARK DR SE
Practice Address - Street 2:SUITE 4
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-6679
Practice Address - Country:US
Practice Address - Phone:540-951-4800
Practice Address - Fax:540-951-3081
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810003586103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
009237T16Medicare ID - Type Unspecified