Provider Demographics
NPI:1629261862
Name:INSUA-LOPEZ, VIVIAN BARBARA (PSY D)
Entity Type:Individual
Prefix:DR
First Name:VIVIAN
Middle Name:BARBARA
Last Name:INSUA-LOPEZ
Suffix:
Gender:F
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16255 VENTURA BLVD
Mailing Address - Street 2:502
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2302
Mailing Address - Country:US
Mailing Address - Phone:818-419-6506
Mailing Address - Fax:818-847-7830
Practice Address - Street 1:16255 VENTURA BLVD
Practice Address - Street 2:502
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2302
Practice Address - Country:US
Practice Address - Phone:818-419-6506
Practice Address - Fax:818-847-7830
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAPSY 26404103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB224028OtherMEDICARE PTAN