Provider Demographics
NPI:1760103501
Name:LOPEZ, SIMON (ACSW)
Entity Type:Individual
Prefix:MR
First Name:SIMON
Middle Name:
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:309 E MOUNTAIN VIEW ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2897
Mailing Address - Country:US
Mailing Address - Phone:254-368-0874
Mailing Address - Fax:
Practice Address - Street 1:309 E MOUNTAIN VIEW ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2897
Practice Address - Country:US
Practice Address - Phone:254-368-0874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-09
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109737101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health