Provider Demographics
NPI:1760982714
Name:LOPEZ, ALEXIS
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:
Last Name:LOPEZ
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 1:8282 WHITE OAK AVE STE 107
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7681
Mailing Address - Country:US
Mailing Address - Phone:909-586-0509
Mailing Address - Fax:909-929-0805
Practice Address - Street 1:8282 WHITE OAK AVE STE 107
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7681
Practice Address - Country:US
Practice Address - Phone:909-586-0509
Practice Address - Fax:909-929-0805
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
CA23231225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician