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General NPI Number Information
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NPI Number | 1699081968
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Entity Type | Individual
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Provider Name | MARCO ANTONIO LOPEZ
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Gender | Male
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Dates
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Enumeration Date | 08/25/2010
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Last Update Date | 07/13/2021
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Provider Practice Location Address
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Address Line | 2940 INLAND EMPIRE BLVD
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City | ONTARIO
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State | CA
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Zip | 91764
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Country | US
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Telephone | 909-458-1350
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Fax | 909-579-8149
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Provider Business Mailing Address
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Address Line | 541 N SAN JACINTO ST
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City | HEMET
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State | CA
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Zip | 92543-3107
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Country | US
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Telephone | 951-791-3687
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Fax | 951-791-3689
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | ASW85389
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License Number State | CA
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