Provider Demographics
NPI:1902481013
Name:LOPEZ, MADISON ROSE (COTA)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:ROSE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:WORTHAM
Mailing Address - State:TX
Mailing Address - Zip Code:76693-0063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:199 COUNTY ROAD 111
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:TX
Practice Address - Zip Code:75840-5405
Practice Address - Country:US
Practice Address - Phone:903-390-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216729224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5835Medicaid