Provider Demographics
NPI:1467227413
Name:LOPEZ, ODALIS MILAGROS
Entity Type:Individual
Prefix:
First Name:ODALIS
Middle Name:MILAGROS
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 1:940 E WILLIAMS ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-5848
Mailing Address - Country:US
Mailing Address - Phone:951-588-2553
Mailing Address - Fax:
Practice Address - Street 1:940 E WILLIAMS ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-5848
Practice Address - Country:US
Practice Address - Phone:951-588-2553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139944106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist