Healthcare Provider Details

I. General information

NPI: 1396324612
Provider Name (Legal Business Name): CYNTHIA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/05/2021
Certification Date: 04/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1358 BLUE OAKS BLVD
ROSEVILLE CA
95678-7040
US

IV. Provider business mailing address

361 ROSEWOOD CT
SAN LEANDRO CA
94577-1731
US

V. Phone/Fax

Practice location:
  • Phone: 916-676-0488
  • Fax: 916-771-4370
Mailing address:
  • Phone: 510-541-6266
  • 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: