Healthcare Provider Details

I. General information

NPI: 1124483474
Provider Name (Legal Business Name): WENDY LOPEZ-LIZARRAGA PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/30/2015
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date: 11/01/2019
Reactivation Date: 11/13/2019

III. Provider practice location address

686 E MILL ST
SAN BERNARDINO CA
92415-0647
US

IV. Provider business mailing address

686 E MILL ST
SAN BERNARDINO CA
92415-0647
US

V. Phone/Fax

Practice location:
  • Phone: 909-798-8589
  • Fax:
Mailing address:
  • Phone: 909-798-8589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberPSY9402603
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: