Provider Demographics
NPI:1770948457
Name:TAVAREZ LOPEZ, LORRAINE (LPES)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:TAVAREZ LOPEZ
Suffix:
Gender:F
Credentials:LPES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1057 OAKLAND DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:SC
Mailing Address - Zip Code:29045-9279
Mailing Address - Country:US
Mailing Address - Phone:754-779-0584
Mailing Address - Fax:
Practice Address - Street 1:1057 OAKLAND DR
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:SC
Practice Address - Zip Code:29045-9279
Practice Address - Country:US
Practice Address - Phone:754-779-0584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-22
Last Update Date:2024-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X, 103TB0200X
SC4657103TM1800X, 103TS0200X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Yes252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLP1011Medicaid