Provider Demographics
NPI:1669131975
Name:LOPEZ, ILIANA RENEE
Entity type:Individual
Prefix:
First Name:ILIANA
Middle Name:RENEE
Last Name: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 1:10721 VISTA ALEGRE DR
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79935-3604
Mailing Address - Country:US
Mailing Address - Phone:915-549-6240
Mailing Address - Fax:
Practice Address - Street 1:12150 TED HOUGHTON
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-6988
Practice Address - Country:US
Practice Address - Phone:915-937-8601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117192235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist