MEDICARE: MAYRA PEREZ 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	1041C0700X	Clinical Social Worker	97377	CA
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	RI-P0908271359	CA

General Provider Information

NPI Number	:	1669605374
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYRA PEREZ LOPEZ

Provider Business Mailing Address
First Line	:	7425 RANCHO LOS GUILICOS RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-6519
Country	:	US
Telephone Number	:	707-565-6319
Fax Number	:

Provider Business Practice Location Address
First Line	:	7425 RANCHO LOS GUILICOS RD
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95409-6519
Country	:	US
Telephone Number	:	707-565-6318
Fax Number	:

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

Provider Enumeration Date	:	08/27/2009
Last Update Date	:	11/14/2021

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