Basic Information
| Provider Information | |||||||||
| NPI: | 1053751990 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | FRANCISCO | ||||||||
| MiddleName: | |||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 MAIN ST FL 2 | ||||||||
| Address2: | ATTN: CREDENTIALING DEPT | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064572845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603476971 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 85 LAFAYETTE STREET | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8902243642 | ||||||||
| FaxNumber: | 8602242760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2013 | ||||||||
| LastUpdateDate: | 06/25/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 00-XXXX | CT | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 004236338 | 05 | CT | MEDICAID |