Provider Demographics
NPI:1336288257
Name:LOPEZ, DANIEL L (PHD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 BROADWAY ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-5719
Mailing Address - Country:US
Mailing Address - Phone:210-822-7321
Mailing Address - Fax:210-736-1867
Practice Address - Street 1:5625 BROADWAY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-5719
Practice Address - Country:US
Practice Address - Phone:210-822-7321
Practice Address - Fax:210-736-1867
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24076103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXGO3COtherBCBS
TX276574OtherVALUE OPTIONS
TX0004625076OtherAETNA
TX00551PMedicare ID - Type Unspecified