Provider Demographics
NPI:1578853545
Name:LOPEZ, DANA CARSON (PSYD)
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:CARSON
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11440 W BERNARDO CT STE 256
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-1653
Mailing Address - Country:US
Mailing Address - Phone:619-752-4450
Mailing Address - Fax:
Practice Address - Street 1:11440 W BERNARDO CT STE 256
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92127-1653
Practice Address - Country:US
Practice Address - Phone:619-752-4450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-12
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY23971103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical