Healthcare Provider Details

I. General information

NPI: 1306547534
Provider Name (Legal Business Name): DILLON ETHAN LOPEZ RSPS, MHPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 BLANCO RD STE 126
SAN ANTONIO TX
78216-4361
US

IV. Provider business mailing address

7400 BLANCO RD STE 126
SAN ANTONIO TX
78216-4361
US

V. Phone/Fax

Practice location:
  • Phone: 210-627-4017
  • Fax:
Mailing address:
  • Phone: 210-627-4017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246R00000X
TaxonomyPathology Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: