Provider Demographics
NPI:1326573114
Name:LOPEZ, DESIREE MARIE
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:MARIE
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 1:17621 IRVINE BLVD STE 214
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3131
Mailing Address - Country:US
Mailing Address - Phone:714-760-4200
Mailing Address - Fax:
Practice Address - Street 1:17621 IRVINE BLVD STE 214
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3131
Practice Address - Country:US
Practice Address - Phone:714-760-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA125101106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist