Basic Information
| Provider Information | |||||||||
| NPI: | 1164992467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | GIOVANNY | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183343986 | ||||||||
| FaxNumber: | 7183345006 | ||||||||
| Practice Location | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183343986 | ||||||||
| FaxNumber: | 7183345006 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2018 | ||||||||
| LastUpdateDate: | 06/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 102571 | NY | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 191501 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 102571 | 01 | NY | NY STATE LICENSE MASTER OF SOCIAL WORK | OTHER |