Provider Demographics
NPI:1861081382
Name:LOPEZ, JOSELIN MIRELLA
Entity type:Individual
Prefix:MISS
First Name:JOSELIN
Middle Name:MIRELLA
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 1:614 W MANCHESTER BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1683
Mailing Address - Country:US
Mailing Address - Phone:310-412-3365
Mailing Address - Fax:310-412-3365
Practice Address - Street 1:614 W MANCHESTER BLVD STE 104
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1683
Practice Address - Country:US
Practice Address - Phone:310-412-3365
Practice Address - Fax:310-412-3365
Is Sole Proprietor?:No
Enumeration Date:2021-01-11
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA11491101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)