Healthcare Provider Details

I. General information

NPI: 1821556549
Provider Name (Legal Business Name): MS. MARIA ELOISA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/12/2019
Last Update Date: 01/12/2024
Certification Date: 01/12/2024
Deactivation Date: 03/11/2020
Reactivation Date: 04/08/2020

III. Provider practice location address

10990 WILSHIRE BLVD STE 250
LOS ANGELES CA
90024-3932
US

IV. Provider business mailing address

PO BOX 1215
GARDENA CA
90249-0215
US

V. Phone/Fax

Practice location:
  • Phone: 415-360-3833
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: