Healthcare Provider Details

I. General information

NPI: 1124932611
Provider Name (Legal Business Name): RAUL LOPEZ RADT TRAINEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4930 NAPLES ST
SAN DIEGO CA
92110-3820
US

IV. Provider business mailing address

4224 CAMINO DE LA PLZ APT 26E
SAN DIEGO CA
92173-3033
US

V. Phone/Fax

Practice location:
  • Phone: 619-269-8969
  • Fax:
Mailing address:
  • Phone: 619-748-5495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRT1453220826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: