Provider Demographics
NPI:1699081968
Name:LOPEZ, MARCO ANTONIO
Entity type:Individual
Prefix:
First Name:MARCO
Middle Name:ANTONIO
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 1:541 N SAN JACINTO ST
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543-3107
Mailing Address - Country:US
Mailing Address - Phone:951-791-3687
Mailing Address - Fax:951-791-3689
Practice Address - Street 1:2940 INLAND EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764
Practice Address - Country:US
Practice Address - Phone:909-458-1350
Practice Address - Fax:909-579-8149
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW85389101YM0800X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty