Healthcare Provider Details

I. General information

NPI: 1720352446
Provider Name (Legal Business Name): LUISA GUADALUPE LOPEZ LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE BLDG 2
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

11632 SAYWARD CIR
RIVERSIDE CA
92503-5069
US

V. Phone/Fax

Practice location:
  • Phone: 951-441-0888
  • Fax:
Mailing address:
  • Phone: 310-616-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number101544
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: