Provider Demographics
NPI:1407642036
Name:LOPEZ, GUSTAVO DANIEL (RADT R1500990323)
Entity type:Individual
Prefix:MR
First Name:GUSTAVO
Middle Name:DANIEL
Last Name:LOPEZ
Suffix:
Gender:
Credentials:RADT R1500990323
Other - Prefix:
Other - First Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4125 BALLANTREE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-2015
Mailing Address - Country:US
Mailing Address - Phone:840-207-5572
Mailing Address - Fax:
Practice Address - Street 1:600 3RD ST STE C
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-2748
Practice Address - Country:US
Practice Address - Phone:951-674-5354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-18
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)