Provider Demographics
NPI:1255451852
Name:LOPEZ, GUILLERMO
Entity type:Individual
Prefix:
First Name:GUILLERMO
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 1:225 CABRILLO HWY S
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:HALF MOON BAY
Mailing Address - State:CA
Mailing Address - Zip Code:94019-8200
Mailing Address - Country:US
Mailing Address - Phone:650-573-3714
Mailing Address - Fax:
Practice Address - Street 1:225 CABRILLO HWY S
Practice Address - Street 2:SUITE 200A
Practice Address - City:HALF MOON BAY
Practice Address - State:CA
Practice Address - Zip Code:94019-8200
Practice Address - Country:US
Practice Address - Phone:650-573-3714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IMF36235106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist