Healthcare Provider Details

I. General information

NPI: 1346951498
Provider Name (Legal Business Name): MAYRA TERESA AVILA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 L ST
BAKERSFIELD CA
93301-4522
US

IV. Provider business mailing address

5284 ADOLFO RD STE 100
CAMARILLO CA
93012-6790
US

V. Phone/Fax

Practice location:
  • Phone: 661-868-6100
  • Fax:
Mailing address:
  • Phone: 805-289-0120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number13861
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: