Provider Demographics
NPI:1255897146
Name:LOPEZ, STANLEY M I (CASAC II)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:M
Last Name:LOPEZ
Suffix:I
Gender:M
Credentials:CASAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3985 GOUVERNEUR AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-2939
Mailing Address - Country:US
Mailing Address - Phone:917-650-7032
Mailing Address - Fax:212-602-1895
Practice Address - Street 1:214 W 116TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-2494
Practice Address - Country:US
Practice Address - Phone:212-602-1400
Practice Address - Fax:212-602-1895
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-15
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY8100101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)