Healthcare Provider Details

I. General information

NPI: 1154759660
Provider Name (Legal Business Name): LIBNI LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2013
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 CENTRE ST
SAN DIEGO CA
92103-3410
US

IV. Provider business mailing address

3909 CENTRE ST
SAN DIEGO CA
92103-3410
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-2077
  • Fax: 619-718-6447
Mailing address:
  • Phone: 619-260-3092
  • Fax: 619-718-6447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number77859
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: