Provider Demographics
NPI:1124851365
Name:LOPEZ, THERESE MARIE
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:MARIE
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 1:271 N DARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-3110
Mailing Address - Country:US
Mailing Address - Phone:323-541-2584
Mailing Address - Fax:
Practice Address - Street 1:CAMINO DEL MOLINO 16
Practice Address - Street 2:MONTEALEGRE BAJO
Practice Address - City:JEREZ DE LA FRONTERA
Practice Address - State:CADIZ
Practice Address - Zip Code:11406
Practice Address - Country:ES
Practice Address - Phone:626-541-2584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-22
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP19636235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist