Healthcare Provider Details

I. General information

NPI: 1164718581
Provider Name (Legal Business Name): JOSE HIGAREDA LOPEZ COUNSELOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 MANOR PLAZA
PACIFICA CA
94044
US

IV. Provider business mailing address

4141 FERN GROVE CT
MODESTO CA
95356
US

V. Phone/Fax

Practice location:
  • Phone: 650-355-8787
  • Fax: 650-355-8780
Mailing address:
  • Phone: 650-355-8787
  • Fax: 650-355-8780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: