Provider Demographics
NPI:1295132330
Name:LOPEZ, MIRTA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:MIRTA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:MIRTA
Other - Middle Name:
Other - Last Name:CARRERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:31 S FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3455
Mailing Address - Country:US
Mailing Address - Phone:973-704-3926
Mailing Address - Fax:
Practice Address - Street 1:31 S FULLERTON AVE
Practice Address - Street 2:2ND FLR
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3455
Practice Address - Country:US
Practice Address - Phone:973-783-3030
Practice Address - Fax:973-783-3033
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC 006539001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical