Provider Demographics
NPI:1750650206
Name:LOPEZ, CONNIE
Entity type:Individual
Prefix:MS
First Name:CONNIE
Middle Name:
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 1:15308 REGALADO ST
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-4433
Mailing Address - Country:US
Mailing Address - Phone:626-627-0311
Mailing Address - Fax:
Practice Address - Street 1:625 FAIR OAKS AVE FL 1
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2630
Practice Address - Country:US
Practice Address - Phone:626-861-4475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-28
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CAMPSS-AJPVHI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171M00000XOtherCASE MANAGER