Healthcare Provider Details

I. General information

NPI: 1225671092
Provider Name (Legal Business Name): BRENDA LIZETH LOPEZ ASW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2019
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3665 KEARNY VILLA RD STE 101
SAN DIEGO CA
92123-1954
US

IV. Provider business mailing address

3665 KEARNY VILLA RD STE 101
SAN DIEGO CA
92123-1954
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-5832
  • Fax:
Mailing address:
  • Phone: 858-966-5832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number119630
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-19-103001
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: