Provider Demographics
NPI:1093391856
Name:LOMELI, BRIANNA MICHELLE
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:MICHELLE
Last Name:LOMELI
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 1:3555 KENYON ST STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5341
Mailing Address - Country:US
Mailing Address - Phone:619-600-0683
Mailing Address - Fax:619-600-0683
Practice Address - Street 1:3555 KENYON ST STE 101
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5341
Practice Address - Country:US
Practice Address - Phone:619-600-0683
Practice Address - Fax:619-600-0683
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA206KQP3HMedicaid