Provider Demographics
NPI:1356813182
Name:LOPEZ, MIKE ANGEL
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:ANGEL
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 CHERRY LN STE 101
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337-4311
Mailing Address - Country:US
Mailing Address - Phone:209-647-6200
Mailing Address - Fax:
Practice Address - Street 1:302 CHERRY LN STE 101
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337-4311
Practice Address - Country:US
Practice Address - Phone:209-647-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1007311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical