Provider Demographics
NPI:1699188854
Name:LOPEZ, JOE
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:
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 1:470 E 3RD ST
Mailing Address - Street 2:C
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1629
Mailing Address - Country:US
Mailing Address - Phone:213-620-4712
Mailing Address - Fax:
Practice Address - Street 1:470 E 3RD ST
Practice Address - Street 2:C
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1629
Practice Address - Country:US
Practice Address - Phone:213-620-4712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2018-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF87134101YM0800X
106H00000X
CA104467106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health