MEDICARE: GRISELDA DIAZ -LOPEZ

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1649861311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRISELDA DIAZ -LOPEZ

Provider Business Mailing Address
First Line	:	21600 OXNARD ST STE 1800
Second Line	:
City	:	WOODLAND HILLS
State	:	CA
Zip	:	91367-7807
Country	:	US
Telephone Number	:	818-345-2345
Fax Number	:	--

Provider Business Practice Location Address
First Line	:	16276 N LAKE ST
Second Line	:
City	:	MADERA
State	:	CA
Zip	:	93638-1615
Country	:	US
Telephone Number	:	559-598-6933
Fax Number	:	--

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

Provider Enumeration Date	:	01/26/2021
Last Update Date	:	01/26/2021

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