Provider Demographics
NPI:1851789283
Name:LOPEZ, MARISOL
Entity Type:Individual
Prefix:
First Name:MARISOL
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 1:13922 CERISE AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-8688
Mailing Address - Country:US
Mailing Address - Phone:310-679-4994
Mailing Address - Fax:
Practice Address - Street 1:13922 CERISE AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-8688
Practice Address - Country:US
Practice Address - Phone:310-679-4994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2770224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant