Healthcare Provider Details

I. General information

NPI: 1497578512
Provider Name (Legal Business Name): NANCY BREANNA COTOM-LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E WARDLOW RD
LONG BEACH CA
90807-4628
US

IV. Provider business mailing address

850 E WARDLOW RD
LONG BEACH CA
90807-4628
US

V. Phone/Fax

Practice location:
  • Phone: 562-481-2895
  • Fax:
Mailing address:
  • Phone: 562-481-2895
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW123728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: