Provider Demographics
NPI:1053168799
Name:LOPEZ, CHARITY R (MSW,LCSW, CSAC, CSIT)
Entity type:Individual
Prefix:
First Name:CHARITY
Middle Name:R
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MSW,LCSW, CSAC, CSIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30401 MOUNTAIN LN
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-3442
Mailing Address - Country:US
Mailing Address - Phone:765-618-7021
Mailing Address - Fax:
Practice Address - Street 1:30401 MOUNTAIN LN
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-3442
Practice Address - Country:US
Practice Address - Phone:262-455-4018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17092132101YA0400X
WI111601231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty