Healthcare Provider Details

I. General information

NPI: 1861081382
Provider Name (Legal Business Name): MISS JOSELIN MIRELLA LOPEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 BLOOMFIELD AVE
SANTA FE SPRINGS CA
90670-4655
US

IV. Provider business mailing address

614 W MANCHESTER BLVD STE 104
INGLEWOOD CA
90301-1683
US

V. Phone/Fax

Practice location:
  • Phone: 562-906-2685
  • Fax:
Mailing address:
  • Phone: 310-412-3365
  • Fax: 310-412-3365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11491
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: