Provider Demographics
NPI:1073313391
Name:LOPEZ, TISHNA M (NYCPS4786)
Entity type:Individual
Prefix:MS
First Name:TISHNA
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:
Credentials:NYCPS4786
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 BEACH 28TH ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-2293
Mailing Address - Country:US
Mailing Address - Phone:718-877-2153
Mailing Address - Fax:
Practice Address - Street 1:225 BEACH 28TH ST UNIT 1
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-2293
Practice Address - Country:US
Practice Address - Phone:718-877-2153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist