Provider Demographics
NPI:1902975444
Name:LOPEZ, SALVADOR JR (PHD)
Entity Type:Individual
Prefix:
First Name:SALVADOR
Middle Name:
Last Name:LOPEZ
Suffix:JR
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 BROADWAY ST
Mailing Address - Street 2:SUITE 218
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-3743
Mailing Address - Country:US
Mailing Address - Phone:210-413-9779
Mailing Address - Fax:210-239-6868
Practice Address - Street 1:7201 BROADWAY ST
Practice Address - Street 2:SUITE 218
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-3743
Practice Address - Country:US
Practice Address - Phone:210-413-9779
Practice Address - Fax:210-239-6868
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX22593103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX680015367OtherMEDICARE RAILROAD
TX00N83ROtherBCBS
TX035101701Medicaid
TX035101701Medicaid