Provider Demographics
NPI:1487264784
Name:LOPEZ, CHRISTA M (RBT)
Entity type:Individual
Prefix:
First Name:CHRISTA
Middle Name:M
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:660 WOODCREST DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-7008
Mailing Address - Country:US
Mailing Address - Phone:951-963-4514
Mailing Address - Fax:
Practice Address - Street 1:5075 SHOREHAM PL STE 115
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92122-5927
Practice Address - Country:US
Practice Address - Phone:858-272-2662
Practice Address - Fax:858-272-2661
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-03
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-19-109115106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty