Provider Demographics
NPI:1023572583
Name:LOPEZ, MYRA DINA (ACSW)
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:DINA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15388 LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-2825
Mailing Address - Country:US
Mailing Address - Phone:760-552-9556
Mailing Address - Fax:
Practice Address - Street 1:15434 W SAGE ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-9751
Practice Address - Country:US
Practice Address - Phone:760-843-0506
Practice Address - Fax:760-843-0507
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-29
Last Update Date:2021-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW966581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical