Basic Information
| Provider Information | |||||||||
| NPI: | 1689118598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | MAIRA | ||||||||
| MiddleName: | YESENIA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11300 FOOTHILL BLVD UNIT 41 | ||||||||
| Address2: | |||||||||
| City: | LAKE VIEW TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913426749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184708418 | ||||||||
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| Practice Location | |||||||||
| Address1: | 565 S. BRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188980223 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2016 | ||||||||
| LastUpdateDate: | 06/06/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | 113558 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.