Healthcare Provider Details

I. General information

NPI: 1093158016
Provider Name (Legal Business Name): RICARDO MARTIN LOPEZ MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2013
Last Update Date: 04/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 W 97TH ST
LOS ANGELES CA
90003-3968
US

IV. Provider business mailing address

439 W 97TH ST
LOS ANGELES CA
90003-3968
US

V. Phone/Fax

Practice location:
  • Phone: 323-754-2856
  • Fax: 323-754-1843
Mailing address:
  • Phone: 323-754-2856
  • Fax: 323-754-1843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: