Provider Demographics
NPI:1700571239
Name:LOPEZ BLACK, ERICKA A (MBA)
Entity Type:Individual
Prefix:
First Name:ERICKA
Middle Name:A
Last Name:LOPEZ BLACK
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:ERICKA
Other - Middle Name:A
Other - Last Name:MENJIVAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10261 TRADEMARK ST
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5805
Mailing Address - Country:US
Mailing Address - Phone:909-481-9333
Mailing Address - Fax:
Practice Address - Street 1:10261 TRADEMARK ST
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5805
Practice Address - Country:US
Practice Address - Phone:909-481-9333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst