Provider Demographics
NPI:1871625384
Name:LOPEZ-WILLIS, THERESA PEARL (MS,CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:PEARL
Last Name:LOPEZ-WILLIS
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6870 ALHAMBRA CT
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-8952
Mailing Address - Country:US
Mailing Address - Phone:505-644-2704
Mailing Address - Fax:
Practice Address - Street 1:1001 S DIAMOND AVE
Practice Address - Street 2:
Practice Address - City:DEMING
Practice Address - State:NM
Practice Address - Zip Code:88030-4710
Practice Address - Country:US
Practice Address - Phone:505-546-0427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1698235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist