Provider Demographics
NPI:1730638693
Name:LOPEZ, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AMFT
Mailing Address - Street 1:1812 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-8014
Mailing Address - Country:US
Mailing Address - Phone:909-748-0259
Mailing Address - Fax:
Practice Address - Street 1:1812 W PARK AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-8014
Practice Address - Country:US
Practice Address - Phone:909-748-0259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA101460106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program