Provider Demographics
NPI:1396528949
Name:BOETA-LOPEZ, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:BOETA-LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-5445
Mailing Address - Country:US
Mailing Address - Phone:773-414-3483
Mailing Address - Fax:
Practice Address - Street 1:8348 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2436
Practice Address - Country:US
Practice Address - Phone:312-298-9402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX89396101YP2500X
IL178018543101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional