1023820263 NPI number — ANDREA CAROLINE LOPEZ SSP, NCSP

Table of content: ANDREA CAROLINE LOPEZ SSP, NCSP (NPI 1023820263)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023820263 NPI number — ANDREA CAROLINE LOPEZ SSP, NCSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOPEZ
Provider First Name:
ANDREA
Provider Middle Name:
CAROLINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SSP, NCSP
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:
1023820263
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1089 BOSKYDELL RD APT 23
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARBONDALE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62902-6107
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-571-1566
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4505 W DEYOUNG ST STE 203C
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARION
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62959-5899
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-283-2222
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/24/2025

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: 103TS0200X , with the licence number:  2557889 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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