Provider Demographics
NPI:1861109522
Name:LOPEZ, BRIAN ROBERTO (PSYD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ROBERTO
Last Name:LOPEZ
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 JUNIPERO SERRA BLVD
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014-3891
Mailing Address - Country:US
Mailing Address - Phone:650-991-6200
Mailing Address - Fax:
Practice Address - Street 1:3580 WILSHIRE BLVD STE 2000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2533
Practice Address - Country:US
Practice Address - Phone:213-381-1250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-02
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34006103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist