=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376202093
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NAYELY LISETTE LOPEZ
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2021
-----------------------------------------------------
Last Update Date | 08/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20342 FLANAGAN ROAD
-----------------------------------------------------
City | TRABUCO CANYON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-582-8832
-----------------------------------------------------
Fax | 818-582-8836
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 E SANTA ANA ST
-----------------------------------------------------
City | ANAHEIM
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92805-4309
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-883-9012
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | R1463750322
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------