MEDICARE: LIZETH MAHALALEEL LOPEZ GASTELUM LICENCIADO

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	25-439749	CA

General Provider Information

NPI Number	:	1659203974
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIZETH MAHALALEEL LOPEZ GASTELUM LICENCIADO

Provider Business Mailing Address
First Line	:	254 E 2ND ST PMB87 356
Second Line	:
City	:	CALEXICO
State	:	CA
Zip	:	92231
Country	:	US
Telephone Number	:	510-807-8567
Fax Number	:

Provider Business Practice Location Address
First Line	:	16485 N STADIUM WAY UNIT 1091
Second Line	:
City	:	SURPRISE
State	:	AZ
Zip	:	85374-4380
Country	:	US
Telephone Number	:	510-807-8567
Fax Number	:

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

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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