Provider Demographics
NPI:1356123319
Name:LOPEZ, BRANDI GINAI
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:GINAI
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:GINAI
Other - Last Name:BRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9333 S THROOP ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60620-3623
Mailing Address - Country:US
Mailing Address - Phone:773-263-1751
Mailing Address - Fax:
Practice Address - Street 1:9333 S THROOP ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60620-3623
Practice Address - Country:US
Practice Address - Phone:773-263-1751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.010259101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional