=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710453626
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANGELA ROSALIA LOPEZ LOPEZ OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2018
-----------------------------------------------------
Last Update Date | 07/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 RIDGEBACK RD STE 2
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-6983
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-650-6636
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3288 ADAMS AVE
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92116-1646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-356-3117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 19249
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------