Provider Demographics
NPI:1154995785
Name:LOPEZ, LAURA (PTA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3802 PRONGHORN LN
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-3064
Mailing Address - Country:US
Mailing Address - Phone:719-429-5827
Mailing Address - Fax:
Practice Address - Street 1:100 SAN CARLOS RD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2651
Practice Address - Country:US
Practice Address - Phone:719-568-9536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0012714225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant