Provider Demographics
NPI:1265884811
Name:LOPEZ, KATHRYN SCOTT
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:SCOTT
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:SCOTT
Other - Last Name:WIENCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 252
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95436-0252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1648 DRUMMOND LANE
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648
Practice Address - Country:US
Practice Address - Phone:916-800-3631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123703106H00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program