Provider Demographics
NPI:1336814201
Name:LOPEZ, LEON DAVID (MBA, LMSW)
Entity Type:Individual
Prefix:
First Name:LEON
Middle Name:DAVID
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MBA, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2068 VEREDA JOSEFITA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3310
Mailing Address - Country:US
Mailing Address - Phone:505-920-2323
Mailing Address - Fax:
Practice Address - Street 1:2068 VEREDA JOSEFITA
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3310
Practice Address - Country:US
Practice Address - Phone:505-920-2323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-12
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YA0400X, 101YM0800X, 102X00000X, 1041C0700X, 106H00000X
NMM-08362104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist