Healthcare Provider Details

I. General information

NPI: 1881068450
Provider Name (Legal Business Name): JOSE DE JESUS LOPEZ ANDRADE PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 04/15/2025
Certification Date: 04/15/2025
Deactivation Date: 01/31/2018
Reactivation Date: 02/01/2022

III. Provider practice location address

510 S VERMONT AVE
LOS ANGELES CA
90020-1912
US

IV. Provider business mailing address

510 S VERMONT AVE
LOS ANGELES CA
90020-1912
US

V. Phone/Fax

Practice location:
  • Phone: 310-253-6332
  • Fax:
Mailing address:
  • Phone: 310-253-6332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: