Provider Demographics
NPI:1316476203
Name:LOPEZ, ROBERT JR
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JR
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 1:6707 GALLOWAY WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-6363
Mailing Address - Country:US
Mailing Address - Phone:916-544-2157
Mailing Address - Fax:
Practice Address - Street 1:6707 GALLOWAY WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-6363
Practice Address - Country:US
Practice Address - Phone:916-544-2157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician