Provider Demographics
NPI:1124163191
Name:LOPEZ, DAVID C (LCSW)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SAINT MARY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4343
Mailing Address - Country:US
Mailing Address - Phone:318-687-4812
Mailing Address - Fax:318-687-4847
Practice Address - Street 1:620 S GROVE ST STE 105
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:TX
Practice Address - Zip Code:75670-5295
Practice Address - Country:US
Practice Address - Phone:903-702-7900
Practice Address - Fax:903-702-7904
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA73091041C0700X
TXS061201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX06120OtherTDSHS
TX168013402Medicaid