Provider Demographics
NPI:1356059059
Name:MIYAKI LOPEZ, SEAN (MOT)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:MIYAKI LOPEZ
Suffix:
Gender:M
Credentials:MOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 ELM ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2500
Mailing Address - Country:US
Mailing Address - Phone:505-727-3601
Mailing Address - Fax:505-727-9840
Practice Address - Street 1:505 ELM ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2500
Practice Address - Country:US
Practice Address - Phone:505-727-3601
Practice Address - Fax:505-727-9840
Is Sole Proprietor?:No
Enumeration Date:2022-11-10
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMOT4676225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMOT4676OtherNM OT LICENSE