Provider Demographics
NPI:1760362701
Name:LOPEZ, EVON
Entity type:Individual
Prefix:
First Name:EVON
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4939 W FULLERTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60639-2505
Mailing Address - Country:US
Mailing Address - Phone:312-600-5061
Mailing Address - Fax:
Practice Address - Street 1:2 S ADDISON ST
Practice Address - Street 2:
Practice Address - City:BENSENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60106-2126
Practice Address - Country:US
Practice Address - Phone:312-600-5061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-02
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-25-426002106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician