Provider Demographics
NPI:1528606514
Name:LOPEZ, MIRELY
Entity Type:Individual
Prefix:
First Name:MIRELY
Middle Name:
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 1:177 E COLORADO BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-1955
Mailing Address - Country:US
Mailing Address - Phone:844-669-7827
Mailing Address - Fax:657-235-5001
Practice Address - Street 1:177 E COLORADO BLVD STE 200
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-1955
Practice Address - Country:US
Practice Address - Phone:844-669-7827
Practice Address - Fax:657-235-5001
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician