Provider Demographics
NPI:1063821676
Name:LOPEZ, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 33568
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163
Mailing Address - Country:US
Mailing Address - Phone:619-977-7201
Mailing Address - Fax:619-374-7134
Practice Address - Street 1:17595 ALMAHURST STREET
Practice Address - Street 2:SUITE 100A
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91748
Practice Address - Country:US
Practice Address - Phone:626-344-4434
Practice Address - Fax:619-374-3471
Is Sole Proprietor?:No
Enumeration Date:2014-08-07
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-16753103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst