Basic Information
| Provider Information | |||||||||
| NPI: | 1891163762 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | ASW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4760 SEPULVEDA BLVD | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902304820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103906612 | ||||||||
| FaxNumber: | 3103985690 | ||||||||
| Practice Location | |||||||||
| Address1: | 672 S LA FAYETTE PARK PL STE 6 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900573224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2133813626 | ||||||||
| FaxNumber: | 2133808923 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2015 | ||||||||
| LastUpdateDate: | 02/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | CA | N | Behavioral Health & Social Service Providers | Social Worker | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | ASW71814 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.