Healthcare Provider Details

I. General information

NPI: 1407718034
Provider Name (Legal Business Name): STEPHANIE LOPEZ
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 SPRUCE ST STE 102
RIVERSIDE CA
92507-7403
US

IV. Provider business mailing address

100 N PACIFIC COAST HWY STE 1400
EL SEGUNDO CA
90245-5602
US

V. Phone/Fax

Practice location:
  • Phone: 951-357-6926
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: