Basic Information
Provider Information | |||||||||
NPI: | 1891976882 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LOPEZ | ||||||||
FirstName: | ERIC | ||||||||
MiddleName: | EDWARDS | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1848 SE 1ST AVE | ||||||||
Address2: |   | ||||||||
City: | FORT LAUDERDALE | ||||||||
State: | FL | ||||||||
PostalCode: | 33316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9548859500 | ||||||||
FaxNumber: | 9548859444 | ||||||||
Practice Location | |||||||||
Address1: | 83 E SHAW AVE STE 102 | ||||||||
Address2: |   | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937107616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5592260167 | ||||||||
FaxNumber: | 5592261559 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2007 | ||||||||
LastUpdateDate: | 09/29/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TC0700X | PY10006 | FL | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.