Provider Demographics
NPI:1073632857
Name:LOPEZ, DAVID (MS, MFT)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 MCHENRY VILLAGE WAY STE 14
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4339
Mailing Address - Country:US
Mailing Address - Phone:209-526-1440
Mailing Address - Fax:209-550-4903
Practice Address - Street 1:1400 MITCHELL RD STE 10
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95351-4901
Practice Address - Country:US
Practice Address - Phone:209-626-8118
Practice Address - Fax:209-567-2315
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT50478106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist