Healthcare Provider Details

I. General information

NPI: 1619659513
Provider Name (Legal Business Name): AYLA NICOLE LOPEZ ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 08/04/2023
Certification Date: 08/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 RIVERVIEW DR
JURUPA VALLEY CA
92509-6611
US

IV. Provider business mailing address

3924 RIVERVIEW DR
JURUPA VALLEY CA
92509-6611
US

V. Phone/Fax

Practice location:
  • Phone: 951-360-4175
  • Fax:
Mailing address:
  • Phone: 909-418-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number115223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: