Provider Demographics
NPI:1932369956
Name:LOPEZ, ROBIN M (LSW)
Entity Type:Individual
Prefix:
First Name:ROBIN
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:ROBIN
Other - Middle Name:M
Other - Last Name:BAILLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-814-9100
Mailing Address - Fax:
Practice Address - Street 1:414 SHOUP AVE W
Practice Address - Street 2:SUITE B
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5042
Practice Address - Country:US
Practice Address - Phone:208-814-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW - 33723104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1932369956Medicaid