Provider Demographics
NPI:1649369083
Name:MORALES, MANUEL LOPEZ (PHD LIC MD)
Entity type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:LOPEZ
Last Name:MORALES
Suffix:
Gender:M
Credentials:PHD LIC MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:52F QUEEN CAROLINE CT
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:MD
Mailing Address - Zip Code:21619
Mailing Address - Country:US
Mailing Address - Phone:410-643-8077
Mailing Address - Fax:410-643-3777
Practice Address - Street 1:133 DEFENSE HWY 205
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-643-8077
Practice Address - Fax:410-643-3777
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1045103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
R09210Medicare UPIN
3361Medicare ID - Type Unspecified