Provider Demographics
NPI:1982054409
Name:LOPEZ TAVIRA CRUZ, ANNAI (MFT, LMFT)
Entity Type:Individual
Prefix:
First Name:ANNAI
Middle Name:
Last Name:LOPEZ TAVIRA CRUZ
Suffix:
Gender:F
Credentials:MFT, LMFT
Other - Prefix:
Other - First Name:ANNAI
Other - Middle Name:
Other - Last Name:TAVIRA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT, LMFT
Mailing Address - Street 1:824 WHITEHAVEN LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-6666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6015 ATLANTIC BLVD STE A
Practice Address - Street 2:
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1343
Practice Address - Country:US
Practice Address - Phone:770-361-4607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001573106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist