Provider Demographics
NPI:1184374183
Name:LOPEZ, ISAIAH JACOB
Entity type:Individual
Prefix:MR
First Name:ISAIAH
Middle Name:JACOB
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 1:13121 NW MILITARY HWY APT 1214
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78231-1854
Mailing Address - Country:US
Mailing Address - Phone:210-355-0849
Mailing Address - Fax:
Practice Address - Street 1:7400 BLANCO RD STE 115
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-4361
Practice Address - Country:US
Practice Address - Phone:210-657-7400
Practice Address - Fax:888-977-1704
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-22-208585106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101520787600OtherAETNACVSHEALTH SILVER 2 HMO HEALTH INSURANCE