Provider Demographics
NPI:1366221673
Name:LOPEZ, JUSTINE (PRSS/FPRSS/BHCM I)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PRSS/FPRSS/BHCM I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 S HUDSON ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-4215
Mailing Address - Country:US
Mailing Address - Phone:580-301-6154
Mailing Address - Fax:
Practice Address - Street 1:101 S HUDSON ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-4215
Practice Address - Country:US
Practice Address - Phone:580-301-6154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
OK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty