Provider Demographics
NPI:1447014477
Name:LOPEZ, ALYCIA DOMENIQUE
Entity type:Individual
Prefix:
First Name:ALYCIA
Middle Name:DOMENIQUE
Last Name:LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALYCIA
Other - Middle Name:DOMENIQUE
Other - Last Name:MEJIA-EARL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MCPSS
Mailing Address - Street 1:251 LLEWELLYN AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-1940
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:251 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-1940
Practice Address - Country:US
Practice Address - Phone:669-308-7284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator