Provider Demographics
NPI:1114782158
Name:LOPEZ, AMANDA NICHOLE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:NICHOLE
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 1:2657 WALNUT GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEMEAD
Mailing Address - State:CA
Mailing Address - Zip Code:91770-3259
Mailing Address - Country:US
Mailing Address - Phone:626-842-7260
Mailing Address - Fax:
Practice Address - Street 1:1000 CORPORATE CENTER DR STE 120
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-7610
Practice Address - Country:US
Practice Address - Phone:626-495-9420
Practice Address - Fax:408-260-5003
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst