Healthcare Provider Details

I. General information

NPI: 1740746510
Provider Name (Legal Business Name): MIKAELA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2019
Last Update Date: 07/16/2020
Certification Date: 07/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 THE CITY DR S
ORANGE CA
92868-3205
US

IV. Provider business mailing address

16675 SLATE DR UNIT 1234
CHINO HILLS CA
91709-7428
US

V. Phone/Fax

Practice location:
  • Phone: 714-935-6363
  • Fax: 714-935-8112
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: