Provider Demographics
NPI:1053695049
Name:LOPEZ, MARLA
Entity type:Individual
Prefix:
First Name:MARLA
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 1:505 S PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-2656
Mailing Address - Country:US
Mailing Address - Phone:310-519-8723
Mailing Address - Fax:
Practice Address - Street 1:944 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-4228
Practice Address - Country:US
Practice Address - Phone:562-436-3533
Practice Address - Fax:562-436-0043
Is Sole Proprietor?:No
Enumeration Date:2011-10-07
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA091928-II101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7006Medicaid