MEDICARE: LEANN LAILA LOPEZ SUDCC III

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	19301	CA
2	390200000X	Student in an Organized Health Care Education/Training Program	19301	CA

General Provider Information

NPI Number	:	1164245726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEANN LAILA LOPEZ SUDCC III

Provider Business Mailing Address
First Line	:	6838 W SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-7008
Country	:	US
Telephone Number	:	323-461-3161
Fax Number	:

Provider Business Practice Location Address
First Line	:	6838 W SUNSET BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-7008
Country	:	US
Telephone Number	:	323-461-3161
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2024
Last Update Date	:	04/20/2026

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