Provider Demographics
NPI:1346694361
Name:BEDOLLA-LOPEZ, MAYRA
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:
Last Name:BEDOLLA-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 1:525 CABRILLO PARK DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-5017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1679 E ORANGETHORPE AVE UNIT 24
Practice Address - Street 2:
Practice Address - City:ATWOOD
Practice Address - State:CA
Practice Address - Zip Code:92811-1201
Practice Address - Country:US
Practice Address - Phone:714-470-9210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-15
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist