Provider Demographics
NPI:1356477269
Name:LOPEZ, FRED TONY (LPT)
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:TONY
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2315 VILLAGE CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:CA
Mailing Address - Zip Code:95301-2819
Mailing Address - Country:US
Mailing Address - Phone:209-358-3922
Mailing Address - Fax:
Practice Address - Street 1:300 E 15TH ST
Practice Address - Street 2:MARIE GREEN
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95340-6217
Practice Address - Country:US
Practice Address - Phone:209-381-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT15436101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health