Provider Demographics
NPI:1740806488
Name:LOPEZ, NICOLE JEANNE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:JEANNE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:JEANNE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:258 N THOMPSON ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-4311
Mailing Address - Country:US
Mailing Address - Phone:951-441-0861
Mailing Address - Fax:951-358-7829
Practice Address - Street 1:3075 MYERS ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-5525
Practice Address - Country:US
Practice Address - Phone:951-955-7829
Practice Address - Fax:951-358-7829
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-18
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-UNZSWE175T00000X
175T00000X, 171M00000X
CAR1541420124101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator