Provider Demographics
NPI:1053735100
Name:LOPEZ, MANDY (LCSW)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 BLUE MOON DR NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87144-4145
Mailing Address - Country:US
Mailing Address - Phone:505-901-0120
Mailing Address - Fax:
Practice Address - Street 1:6330 RIVERSIDE PLAZA LN NW STE 260
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-2160
Practice Address - Country:US
Practice Address - Phone:505-226-2839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-094671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM13583510OtherCA QH#
NM05852820Medicaid