Provider Demographics
NPI:1669671699
Name:LOPEZ, FREDERICK (PSYCHOLOGIST)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14238 EDGEHILL CT
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92337-0109
Mailing Address - Country:US
Mailing Address - Phone:909-684-4119
Mailing Address - Fax:
Practice Address - Street 1:1012 E COOLEY DR STE B2
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3959
Practice Address - Country:US
Practice Address - Phone:909-251-2449
Practice Address - Fax:909-494-4208
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32140103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00007473Medicaid