Basic Information
| Provider Information | |||||||||
| NPI: | 1568976843 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ CORREA | ||||||||
| FirstName: | JULISSA | ||||||||
| MiddleName: | IVELISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 316 MID VALLEY CTR # 186 | ||||||||
| Address2: | |||||||||
| City: | CARMEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 939238516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009916070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 185 MITTIE HADDOCK DR | ||||||||
| Address2: | |||||||||
| City: | CAMERON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283269379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3867179131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2017 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106E00000X | 8744 | Y |
No ID Information.