Provider Demographics
NPI:1235658956
Name:LOPEZ, ROSA ANGELA (MC)
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:ANGELA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13800 HEACOCK ST STE D111
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-3340
Mailing Address - Country:US
Mailing Address - Phone:951-653-1800
Mailing Address - Fax:951-653-1815
Practice Address - Street 1:13800 HEACOCK ST STE D111
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-3340
Practice Address - Country:US
Practice Address - Phone:951-653-1800
Practice Address - Fax:951-653-1815
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CAAPCC4775101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner