Provider Demographics
NPI:1457871592
Name:LOPEZ, IESHA VICKTORIA (LCSW)
Entity type:Individual
Prefix:
First Name:IESHA
Middle Name:VICKTORIA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:IESHA
Other - Middle Name:VICKTORIA
Other - Last Name:BAILEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:750 N FREEDOM BLVD
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1677
Mailing Address - Country:US
Mailing Address - Phone:801-373-4760
Mailing Address - Fax:801-373-0639
Practice Address - Street 1:750 N FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601
Practice Address - Country:US
Practice Address - Phone:801-373-4760
Practice Address - Fax:801-373-0639
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10382224-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical