1700010857 NPI number — BERTHA IRIS LOPEZ MS,CCC-SLP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700010857 NPI number — BERTHA IRIS LOPEZ MS,CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
BERTHA
Provider Middle Name:
IRIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS,CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700010857
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2007 CRESTWOOD PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76209-2105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-367-8101
Provider Business Mailing Address Fax Number:
940-239-9891

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2007 CRESTWOOD PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76209-2105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-367-8101
Provider Business Practice Location Address Fax Number:
940-239-9891
Provider Enumeration Date:
05/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  101334 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201265003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201265004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20122650031700010857 . This is a "COOK CHILDREN'S HEALTH PLAN/STAR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: LB00802 . This is a "COOK CHILDREN'S HEALTH PLAN(CHIP)" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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