Provider Demographics
NPI:1629834239
Name:LOPEZ, MICHAEL GERALD
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:GERALD
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 1:163 4TH ST
Mailing Address - Street 2:
Mailing Address - City:FILLMORE
Mailing Address - State:CA
Mailing Address - Zip Code:93015-1417
Mailing Address - Country:US
Mailing Address - Phone:805-206-5882
Mailing Address - Fax:
Practice Address - Street 1:163 4TH ST
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:CA
Practice Address - Zip Code:93015-1417
Practice Address - Country:US
Practice Address - Phone:805-206-5882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician