Provider Demographics
NPI:1306547534
Name:LOPEZ, DILLON ETHAN (RSPS, MHPS)
Entity type:Individual
Prefix:
First Name:DILLON
Middle Name:ETHAN
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:RSPS, MHPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 BLANCO RD STE 126
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-4361
Mailing Address - Country:US
Mailing Address - Phone:210-627-4017
Mailing Address - Fax:
Practice Address - Street 1:7400 BLANCO RD STE 126
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:210-627-4017
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 246R00000X, 246ZE0500X
TX175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Pathology
No246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG