Healthcare Provider Details

I. General information

NPI: 1699081968
Provider Name (Legal Business Name): MARCO ANTONIO LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2010
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 INLAND EMPIRE BLVD
ONTARIO CA
91764
US

IV. Provider business mailing address

541 N SAN JACINTO ST
HEMET CA
92543-3107
US

V. Phone/Fax

Practice location:
  • Phone: 909-458-1350
  • Fax: 909-579-8149
Mailing address:
  • Phone: 951-791-3687
  • Fax: 951-791-3689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW85389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: