Healthcare Provider Details

I. General information

NPI: 1750146403
Provider Name (Legal Business Name): MARK ANTHONY LOPEZ EDS., NSCP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2024
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 W BALL RD
ANAHEIM CA
92802-1626
US

IV. Provider business mailing address

501 N CRESCENT WAY
ANAHEIM CA
92801-5401
US

V. Phone/Fax

Practice location:
  • Phone: 714-234-3198
  • Fax:
Mailing address:
  • Phone: 714-234-3198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number210116935
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: