Basic Information
| Provider Information | |||||||||
| NPI: | 1124163191 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 SAINT MARY PL | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711014343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186874812 | ||||||||
| FaxNumber: | 3186874847 | ||||||||
| Practice Location | |||||||||
| Address1: | 620 S GROVE ST STE 105 | ||||||||
| Address2: | |||||||||
| City: | MARSHALL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756705295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037027900 | ||||||||
| FaxNumber: | 9037027904 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 7309 | LA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | S06120 | TX | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 06120 | 01 | TX | TDSHS | OTHER |