Provider Demographics
NPI:1366080087
Name:LOPEZ, PRISCILLA C (MASTER CASAC #34980)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:C
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MASTER CASAC #34980
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:131 SAINT NICHOLAS AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-2147
Mailing Address - Country:US
Mailing Address - Phone:646-270-7141
Mailing Address - Fax:
Practice Address - Street 1:3584 JEROME AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-1006
Practice Address - Country:US
Practice Address - Phone:653-153-7718
Practice Address - Fax:699-371-8228
Is Sole Proprietor?:No
Enumeration Date:2019-12-12
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY211110743101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11681Medicaid