Basic Information
| Provider Information | |||||||||
| NPI: | 1205477742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | DANIELLE | ||||||||
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| Credential: | MS, LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2671 | ||||||||
| Address2: | |||||||||
| City: | ANTHONY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880212671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758825100 | ||||||||
| FaxNumber: | 5758821151 | ||||||||
| Practice Location | |||||||||
| Address1: | 785 ANTHONY DRIVE | ||||||||
| Address2: | |||||||||
| City: | ANTHONY | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880212671 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758825100 | ||||||||
| FaxNumber: | 5758821151 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2019 | ||||||||
| LastUpdateDate: | 10/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | T-CTL0206551 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 35650338 | 05 | NM | MEDICAID |