1740686823 NPI number — AMY LOPEZ COUNSELING SERVICES LLC

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 1740686823 NPI number — AMY LOPEZ COUNSELING SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMY LOPEZ COUNSELING SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1740686823
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4402 S 68TH ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GREENFIELD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53220-3479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-955-9804
Provider Business Mailing Address Fax Number:
414-321-0552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4402 S 68TH ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
GREENFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53220-3479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-955-9804
Provider Business Practice Location Address Fax Number:
414-321-0552
Provider Enumeration Date:
11/17/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LOPEZ
Authorized Official First Name:
AMY
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
SOLE MEMBER/OWNER
Authorized Official Telephone Number:
262-955-9804

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1639301104 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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