Provider Demographics
NPI:1336797497
Name:LOPEZ, NEREYDA ISABEL
Entity Type:Individual
Prefix:
First Name:NEREYDA
Middle Name:ISABEL
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 1:20 N DEWITT AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93612-0311
Mailing Address - Country:US
Mailing Address - Phone:559-367-1473
Mailing Address - Fax:
Practice Address - Street 1:6601 MCDIVITT DR
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93313-2049
Practice Address - Country:US
Practice Address - Phone:661-520-9292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-30
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician