Basic Information
| Provider Information | |||||||||
| NPI: | 1881068450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LOPEZ ANDRADE | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | DE JESUS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1625 SCHRADER BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900286213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6572102629 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1721 GRIFFIN AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900313312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232214134 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2015 | ||||||||
| LastUpdateDate: | 06/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/31/2018 | ||||||||
| NPIReactivationDate: | 02/01/2022 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225C00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Counselor | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 01536011 | 01 | CA | MEDI-CAL | OTHER |