Provider Demographics
NPI:1356695944
Name:LOPEZ, JUSTEN JOSEPH (ATC, LAT, PES, GTS)
Entity type:Individual
Prefix:
First Name:JUSTEN
Middle Name:JOSEPH
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:ATC, LAT, PES, GTS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 GLENVILLE ST
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-3680
Mailing Address - Country:US
Mailing Address - Phone:518-258-9828
Mailing Address - Fax:
Practice Address - Street 1:10 GLENVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06831-3680
Practice Address - Country:US
Practice Address - Phone:518-258-9828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-03
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002612246Z00000X
FLAL 31592255A2300X
CT16022255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other