Provider Demographics
NPI:1962870378
Name:LOPEZ, MICHELLE ATHENS (MS)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ATHENS
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5124 SILVERBELL LN
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79932-2226
Mailing Address - Country:US
Mailing Address - Phone:915-422-6028
Mailing Address - Fax:
Practice Address - Street 1:18511 HIGHLANDER MEDICS ST
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79906-5327
Practice Address - Country:US
Practice Address - Phone:915-742-9396
Practice Address - Fax:915-742-1704
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-02
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16923235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX741312313Medicaid