Provider Demographics
NPI:1134692221
Name:LOPEZ COTA RUIZ, BRENDA JAQUELINE
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:JAQUELINE
Last Name:LOPEZ COTA RUIZ
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 1:4043 BIG DALTON AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-4309
Mailing Address - Country:US
Mailing Address - Phone:626-393-5181
Mailing Address - Fax:
Practice Address - Street 1:508 S 2ND AVE
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-3012
Practice Address - Country:US
Practice Address - Phone:626-974-8123
Practice Address - Fax:626-974-8198
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW1026421041C0700X, 101YM0800X, 101YM0800X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker