Provider Demographics
NPI:1780159251
Name:LOPEZ, MICHELLE JACOBS (LP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:JACOBS
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-8611
Mailing Address - Country:US
Mailing Address - Phone:786-315-6988
Mailing Address - Fax:888-371-0842
Practice Address - Street 1:1130 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19382-5005
Practice Address - Country:US
Practice Address - Phone:972-677-7951
Practice Address - Fax:888-371-0842
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPS018577103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical