Healthcare Provider Details

I. General information

NPI: 1932767225
Provider Name (Legal Business Name): ALEXIS HEREDIA LOPEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 10/19/2023
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 N CALIFORNIA ST
STOCKTON CA
95202-1515
US

IV. Provider business mailing address

1414 N CALIFORNIA ST
STOCKTON CA
95202-1515
US

V. Phone/Fax

Practice location:
  • Phone: 209-468-8267
  • Fax: 209-468-8024
Mailing address:
  • Phone: 209-468-8267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT141235
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: