Healthcare Provider Details

I. General information

NPI: 1548848294
Provider Name (Legal Business Name): ILSE NATALIE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 04/01/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 PALOMAR AIRPORT RD STE 350
CARLSBAD CA
92011-1451
US

IV. Provider business mailing address

1365 27TH ST # 207
SAN DIEGO CA
92154-3236
US

V. Phone/Fax

Practice location:
  • Phone: 760-710-2460
  • Fax:
Mailing address:
  • Phone: 619-608-3059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: