Provider Demographics
NPI:1477026409
Name:LOPEZ, MOSES II
Entity type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:LOPEZ
Suffix:II
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 1:174 S O ST APT 33
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-2156
Mailing Address - Country:US
Mailing Address - Phone:916-412-5038
Mailing Address - Fax:
Practice Address - Street 1:6030 W OAKS BLVD STE 170
Practice Address - Street 2:
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95765-4437
Practice Address - Country:US
Practice Address - Phone:916-824-3220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-02
Last Update Date:2019-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA08392152OtherKAISER