Provider Demographics
NPI:1740686823
Name:AMY LOPEZ COUNSELING SERVICES LLC
Entity type:Organization
Organization Name:AMY LOPEZ COUNSELING SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:262-955-9804
Mailing Address - Street 1:4402 S 68TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53220-3479
Mailing Address - Country:US
Mailing Address - Phone:262-955-9804
Mailing Address - Fax:414-321-0552
Practice Address - Street 1:4402 S 68TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-3479
Practice Address - Country:US
Practice Address - Phone:262-955-9804
Practice Address - Fax:414-321-0552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-17
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1639301104Medicaid