Provider Demographics
NPI:1265085690
Name:LOPEZ, JUAN JOSE
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
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 1:3405 ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-5037
Mailing Address - Country:US
Mailing Address - Phone:760-845-0782
Mailing Address - Fax:
Practice Address - Street 1:11665 AVENA PL STE 204
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2428
Practice Address - Country:US
Practice Address - Phone:858-200-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1700383825103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst