Healthcare Provider Details

I. General information

NPI: 1740806488
Provider Name (Legal Business Name): NICOLE JEANNE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE JEANNE BROWN

II. Dates (important events)

Enumeration Date: 06/18/2020
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3075 MYERS ST
RIVERSIDE CA
92503-5525
US

IV. Provider business mailing address

258 N THOMPSON ST
HEMET CA
92543-4311
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-7829
  • Fax: 951-358-7829
Mailing address:
  • Phone: 951-441-0861
  • Fax: 951-358-7829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-UNZSWE
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1541420124
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: