MEDICARE: MIA LOPEZ

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1578230157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA LOPEZ

Provider Business Mailing Address
First Line	:	1501 MARIPOSA ST STE 312
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94107-2367
Country	:	US
Telephone Number	:	707-564-6238
Fax Number	:

Provider Business Practice Location Address
First Line	:	1501 MARIPOSA ST STE 312
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94107-2367
Country	:	US
Telephone Number	:	650-260-4670
Fax Number	:

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

Provider Enumeration Date	:	08/23/2021
Last Update Date	:	08/23/2021

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Directions to “ MIA LOPEZ ” Practice Location

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