Provider Demographics
NPI:1225727548
Name:LOPEZ, JUAN CARLOS (LCSW)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 WATERSIDE XING STE 401
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-1588
Mailing Address - Country:US
Mailing Address - Phone:860-731-5522
Mailing Address - Fax:860-731-5536
Practice Address - Street 1:54-56 BOSTON POST ROAD
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226
Practice Address - Country:US
Practice Address - Phone:860-456-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7056104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker