Provider Demographics
NPI:1316292055
Name:LOPEZ, NICOLE (MSED)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41-44 44TH ST APT# F-12
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-2259
Mailing Address - Country:US
Mailing Address - Phone:646-515-1113
Mailing Address - Fax:
Practice Address - Street 1:406 10TH AVE
Practice Address - Street 2:9TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-2320
Practice Address - Country:US
Practice Address - Phone:212-273-6537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool