Provider Demographics
NPI:1386888303
Name:LOPEZ, MALAVIKA
Entity type:Individual
Prefix:MS
First Name:MALAVIKA
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MALAVIKA
Other - Middle Name:
Other - Last Name:BANGAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3726 TIBBETTS ST STE A
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2660
Mailing Address - Country:US
Mailing Address - Phone:951-500-3626
Mailing Address - Fax:
Practice Address - Street 1:3726 TIBBETTS ST STE A
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2660
Practice Address - Country:US
Practice Address - Phone:951-500-3626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT94661106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
0000000000OtherNONE