Basic Information
| Provider Information | |||||||||
| NPI: | 1538448865 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | BLANCA | ||||||||
| MiddleName: | LUCILLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 966 W 21ST ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606084511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
| FaxNumber: | 7736501239 | ||||||||
| Practice Location | |||||||||
| Address1: | 2355 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606083837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732541400 | ||||||||
| FaxNumber: | 7736501239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2011 | ||||||||
| LastUpdateDate: | 01/19/2017 | ||||||||
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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 | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 149018185 | IL | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | IL | MEDICAID |