Provider Demographics
NPI:1447675095
Name:LOPEZ-MARQUEZ, MAURICIO (LCSW)
Entity type:Individual
Prefix:
First Name:MAURICIO
Middle Name:
Last Name:LOPEZ-MARQUEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:MAURICIO
Other - Middle Name:
Other - Last Name:LOPEZ-MARQUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2504 CAMINO ENTRADA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-4851
Mailing Address - Country:US
Mailing Address - Phone:505-471-5006
Mailing Address - Fax:
Practice Address - Street 1:5501 WILSHIRE AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1950
Practice Address - Country:US
Practice Address - Phone:505-218-1552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-09261104100000X
NMC-103181041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker