Provider Demographics
NPI:1346951498
Name:AVILA LOPEZ, MAYRA TERESA
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:TERESA
Last Name:AVILA 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 1:5284 ADOLFO RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-6790
Mailing Address - Country:US
Mailing Address - Phone:805-289-0120
Mailing Address - Fax:
Practice Address - Street 1:1401 L ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-4522
Practice Address - Country:US
Practice Address - Phone:661-868-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13861101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional