Provider Demographics
NPI:1205593100
Name:LOPEZ, MOISES (LSW)
Entity type:Individual
Prefix:
First Name:MOISES
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4350 S CALIFORNIA AVE STE 2F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60632-1263
Mailing Address - Country:US
Mailing Address - Phone:312-428-0734
Mailing Address - Fax:
Practice Address - Street 1:4350 S CALIFORNIA AVE STE 2F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-1263
Practice Address - Country:US
Practice Address - Phone:312-428-0734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-26
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105435104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker