Provider Demographics
NPI:1669659512
Name:LOPEZ, SUSANA AYALA (MS)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:AYALA
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 CAPISTRANO AVE STE E
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-7227
Mailing Address - Country:US
Mailing Address - Phone:805-703-5330
Mailing Address - Fax:805-703-5350
Practice Address - Street 1:5955 CAPISTRANO AVE STE E
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-7227
Practice Address - Country:US
Practice Address - Phone:805-703-5330
Practice Address - Fax:805-703-5350
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CA28957103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program