Provider Demographics
NPI:1952502973
Name:LOPEZ, BERNICE (PTA)
Entity Type:Individual
Prefix:
First Name:BERNICE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16844 EAST SAM GERRY DRIVE
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744
Mailing Address - Country:US
Mailing Address - Phone:626-641-0064
Mailing Address - Fax:
Practice Address - Street 1:4655 RUFFNER ST STE 270
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-2276
Practice Address - Country:US
Practice Address - Phone:800-787-6787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3456225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant