Provider Demographics
NPI:1427108638
Name:LOPEZ, SALLY LORAINE (MA)
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:LORAINE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:#218 METHIS ST.
Mailing Address - Street 2:PASEO DEL SOL
Mailing Address - City:DORADO
Mailing Address - State:PR
Mailing Address - Zip Code:00646-4619
Mailing Address - Country:US
Mailing Address - Phone:787-383-0338
Mailing Address - Fax:787-278-0388
Practice Address - Street 1:# 410 CALLE MENDEZ VIGO
Practice Address - Street 2:SUITE 203
Practice Address - City:DORADO
Practice Address - State:PR
Practice Address - Zip Code:00646-4619
Practice Address - Country:US
Practice Address - Phone:787-383-0338
Practice Address - Fax:787-278-0388
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR001794103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR2936OtherAPS HEALTHCARE
PRA187OtherFIRST MEDICAL
PR543166OtherMEDICAL CARD SYSTEMS
PR219067OtherPREFERRED HEALTH
PR2936OtherAPS HEALTHCARE
PRQ41834Medicare UPIN