Provider Demographics
NPI:1295459402
Name:LOPEZ, DIANA ALISE (LCSW)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:ALISE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17240 OLIVE ST
Mailing Address - Street 2:P.O. BOX #2186
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:287 LORTON AVE
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-4203
Practice Address - Country:US
Practice Address - Phone:800-505-5972
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-30
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0230561041C0700X
CA1099271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical