Provider Demographics
NPI:1962087684
Name:LOPEZ, CRISTA (MA)
Entity type:Individual
Prefix:
First Name:CRISTA
Middle Name:
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 1:25099 CROXLEY GREEN SQ
Mailing Address - Street 2:
Mailing Address - City:ALDIE
Mailing Address - State:VA
Mailing Address - Zip Code:20105-5672
Mailing Address - Country:US
Mailing Address - Phone:571-225-9563
Mailing Address - Fax:
Practice Address - Street 1:10379B DEMOCRACY LN
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2505
Practice Address - Country:US
Practice Address - Phone:703-591-2551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
VA0704013702390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program