Provider Demographics
NPI:1730072612
Name:LOPEZ, KAITLAN ARIEL
Entity type:Individual
Prefix:MRS
First Name:KAITLAN
Middle Name:ARIEL
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6324 W 92ND ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-1406
Mailing Address - Country:US
Mailing Address - Phone:773-865-1201
Mailing Address - Fax:
Practice Address - Street 1:4101 LIBERTY BLVD APT 1
Practice Address - Street 2:
Practice Address - City:WESTMONT
Practice Address - State:IL
Practice Address - Zip Code:60559-1348
Practice Address - Country:US
Practice Address - Phone:630-426-9386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist