Healthcare Provider Details

I. General information

NPI: 1760852750
Provider Name (Legal Business Name): MARISELA LOPEZ-SUAREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARISELA LOPEZ

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 03/10/2024
Certification Date: 03/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 PARKER RD RM 20
RICHMOND CA
94806-2742
US

IV. Provider business mailing address

3000 PARKER RD RM 20
RICHMOND CA
94806-2742
US

V. Phone/Fax

Practice location:
  • Phone: 510-307-4643
  • Fax:
Mailing address:
  • Phone: 510-307-4643
  • Fax: 510-724-8829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number150120277
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF92977
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT133065
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT145499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: