Provider Demographics
NPI:1568976843
Name:LOPEZ CORREA, JULISSA IVELISE
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:IVELISE
Last Name:LOPEZ CORREA
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 1:316 MID VALLEY CTR # 186
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:CA
Mailing Address - Zip Code:93923-8516
Mailing Address - Country:US
Mailing Address - Phone:800-991-6070
Mailing Address - Fax:
Practice Address - Street 1:185 MITTIE HADDOCK DR
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:NC
Practice Address - Zip Code:28326-9379
Practice Address - Country:US
Practice Address - Phone:386-717-9131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-25
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
8744106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst