Provider Demographics
NPI:1558721795
Name:LOPEZ, MIGUEL GONZALO IV
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:GONZALO
Last Name:LOPEZ
Suffix:IV
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:GONZALO
Other - Last Name:LOPEZ
Other - Suffix:IV
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4214 CALMONT AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76107-4311
Mailing Address - Country:US
Mailing Address - Phone:956-648-9222
Mailing Address - Fax:
Practice Address - Street 1:4214 CALMONT AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-4311
Practice Address - Country:US
Practice Address - Phone:956-648-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80456101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional