Healthcare Provider Details

I. General information

NPI: 1073632857
Provider Name (Legal Business Name): DAVID LOPEZ MS, MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 12/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 MITCHELL RD STE 10
MODESTO CA
95351-4901
US

IV. Provider business mailing address

1700 MCHENRY VILLAGE WAY STE 14
MODESTO CA
95350-4339
US

V. Phone/Fax

Practice location:
  • Phone: 209-626-8118
  • Fax: 209-567-2315
Mailing address:
  • Phone: 209-526-1440
  • Fax: 209-550-4903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT50478
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: