Basic Information
| Provider Information | |||||||||
| NPI: | 1699490490 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOPEZ | ||||||||
| FirstName: | SKYLAR | ||||||||
| MiddleName: | P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2440 TULARE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937212281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594434800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2440 TULARE ST | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937212281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594434800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2022 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | AMFT134587 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.