MEDICARE: KRYSTAL DANIELLE LOPEZ PSY.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY32880	CA

General Provider Information

NPI Number	:	1215304308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL DANIELLE LOPEZ PSY.D

Provider Business Mailing Address
First Line	:	13217 JAMBOREE RD STE 708
Second Line	:
City	:	TUSTIN
State	:	CA
Zip	:	92782-9158
Country	:	US
Telephone Number	:	949-228-9776
Fax Number	:	949-281-5538

Provider Business Practice Location Address
First Line	:	19712 MACARTHUR BLVD STE 110
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92612-2407
Country	:	US
Telephone Number	:	949-228-9776
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2015
Last Update Date	:	12/08/2025

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