Healthcare Provider Details

I. General information

NPI: 1740498294
Provider Name (Legal Business Name): MRS. MARISELA LOPEZ LEACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4333 E VINEYARD AVE
OXNARD CA
93036-1013
US

IV. Provider business mailing address

413 SIMON WAY
OXNARD CA
93036-1344
US

V. Phone/Fax

Practice location:
  • Phone: 805-981-5584
  • Fax:
Mailing address:
  • Phone: 805-278-9757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: