Provider Demographics
NPI:1457610214
Name:LOPEZ, KEITH ALBERT (LAC)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:ALBERT
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:T9 FORT MISSOULA
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59804-7298
Mailing Address - Country:US
Mailing Address - Phone:406-532-8400
Mailing Address - Fax:406-543-9316
Practice Address - Street 1:307 E PARK AVE
Practice Address - Street 2:SUITE 207B
Practice Address - City:ANACONDA
Practice Address - State:MT
Practice Address - Zip Code:59711-2320
Practice Address - Country:US
Practice Address - Phone:406-563-7197
Practice Address - Fax:406-563-7685
Is Sole Proprietor?:No
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT14111101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)