Provider Demographics
NPI:1528551686
Name:LOPEZ, LESLIE LILYBEHT
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:LILYBEHT
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 1:12042 PONDEROSA CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-0767
Mailing Address - Country:US
Mailing Address - Phone:909-827-1319
Mailing Address - Fax:
Practice Address - Street 1:1650 SPRUCE ST STE 250
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7429
Practice Address - Country:US
Practice Address - Phone:760-815-7772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health