Provider Demographics
NPI:1053092544
Name:LOPEZ, AMBER-GRACE (RADT)
Entity type:Individual
Prefix:
First Name:AMBER-GRACE
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3837 MCNAB AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-2218
Mailing Address - Country:US
Mailing Address - Phone:562-357-5704
Mailing Address - Fax:
Practice Address - Street 1:901 W VICTORIA ST STE F&G
Practice Address - Street 2:
Practice Address - City:COMPTON
Practice Address - State:CA
Practice Address - Zip Code:90220-5807
Practice Address - Country:US
Practice Address - Phone:310-669-9510
Practice Address - Fax:310-669-9501
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1509280623101YA0400X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)