Provider Demographics
NPI:1104371905
Name:LOPEZ, MAYRA (ACSW)
Entity Type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:VALENCIA
Other - Last Name:CAMPOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:415A W 18TH ST UNIT 1165
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95340-4837
Mailing Address - Country:US
Mailing Address - Phone:209-385-6500
Mailing Address - Fax:
Practice Address - Street 1:1900 G ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340
Practice Address - Country:US
Practice Address - Phone:209-385-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW96461101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1104371905Medicaid