Healthcare Provider Details

I. General information

NPI: 1124557004
Provider Name (Legal Business Name): ANDRES LOPEZ ACSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 ALLSTATE DR
RIVERSIDE CA
92501-1702
US

IV. Provider business mailing address

4590 ALLSTATE DR
RIVERSIDE CA
92501-1702
US

V. Phone/Fax

Practice location:
  • Phone: 909-599-1227
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number83119
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: