Healthcare Provider Details

I. General information

NPI: 1578178570
Provider Name (Legal Business Name): BRIANNA ILENE LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2020
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 W GUTIERREZ ST
SANTA BARBARA CA
93101-3424
US

IV. Provider business mailing address

7612 NEWPORT DR
GOLETA CA
93117-2418
US

V. Phone/Fax

Practice location:
  • Phone: 805-705-5617
  • Fax:
Mailing address:
  • Phone: 626-267-6152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT137968
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: