Provider Demographics
NPI:1134543796
Name:LOPEZ, LINDA B (LCSW)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:B
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:B
Other - Last Name:DURAN PEREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 18
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-0018
Mailing Address - Country:US
Mailing Address - Phone:208-356-4900
Mailing Address - Fax:208-624-4112
Practice Address - Street 1:3729 WOODKING DR STE 1
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4720
Practice Address - Country:US
Practice Address - Phone:208-356-4900
Practice Address - Fax:208-612-6118
Is Sole Proprietor?:No
Enumeration Date:2014-02-18
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-33355104100000X
IDLMSW-35024104100000X
IDLCSW-395921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDLCSW-39592OtherIBOL