Provider Demographics
NPI:1538568894
Name:LOPEZ, IVY GRACE (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:IVY GRACE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8829 180TH ST FL 2
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-4737
Mailing Address - Country:US
Mailing Address - Phone:914-426-9779
Mailing Address - Fax:718-880-1240
Practice Address - Street 1:8829 180TH ST FL 2
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-4737
Practice Address - Country:US
Practice Address - Phone:914-426-9779
Practice Address - Fax:718-880-1240
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-22
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018985174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist