Provider Demographics
NPI:1982145843
Name:LOPEZ, RAQUEL (PT)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 N SIERRA BONITA AVE
Mailing Address - Street 2:APT 3
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-6559
Mailing Address - Country:US
Mailing Address - Phone:313-686-0784
Mailing Address - Fax:
Practice Address - Street 1:1821 WILSHIRE BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5618
Practice Address - Country:US
Practice Address - Phone:310-828-2188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-12
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT2922732251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic