Provider Demographics
NPI:1770283657
Name:LOPEZ, EDGAR
Entity type:Individual
Prefix:MR
First Name:EDGAR
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 W PRAIRIE DR STE G
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3123
Mailing Address - Country:US
Mailing Address - Phone:773-520-7494
Mailing Address - Fax:
Practice Address - Street 1:920 S PRAIRIE DRIVE
Practice Address - Street 2:UNIT G
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:818-782-2211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst