Provider Demographics
NPI:1588781397
Name:LOPEZ, ANTONIA D
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:D
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5314
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-0314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1631 MOURNING DOVE LN
Practice Address - Street 2:
Practice Address - City:LORENA
Practice Address - State:TX
Practice Address - Zip Code:76655-3140
Practice Address - Country:US
Practice Address - Phone:254-723-8217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX084041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical