Healthcare Provider Details

I. General information

NPI: 1730638693
Provider Name (Legal Business Name): THERESA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: THERESA LOPEZ AMFT

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 04/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1812 W PARK AVE
REDLANDS CA
92373-8014
US

IV. Provider business mailing address

1812 W PARK AVE
REDLANDS CA
92373-8014
US

V. Phone/Fax

Practice location:
  • Phone: 909-748-0259
  • Fax:
Mailing address:
  • Phone: 909-748-0259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number101460
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: