Healthcare Provider Details

I. General information

NPI: 1659203974
Provider Name (Legal Business Name): LIZETH MAHALALEEL LOPEZ GASTELUM LICENCIADO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2026
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16485 N STADIUM WAY UNIT 1091
SURPRISE AZ
85374-4380
US

IV. Provider business mailing address

254 E 2ND ST PMB87 356
CALEXICO CA
92231
US

V. Phone/Fax

Practice location:
  • Phone: 510-807-8567
  • Fax:
Mailing address:
  • Phone: 510-807-8567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number25-439749
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: