Provider Demographics
NPI:1740898980
Name:LOPEZ, MALIAH AMEYALI
Entity type:Individual
Prefix:
First Name:MALIAH
Middle Name:AMEYALI
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 1:1609 S PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-4325
Mailing Address - Country:US
Mailing Address - Phone:909-418-8986
Mailing Address - Fax:
Practice Address - Street 1:9645 ARROW RTE STE A
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4554
Practice Address - Country:US
Practice Address - Phone:909-948-5747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3016594225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor