Individual
GLEN MARTIN LOPEZ
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LPT
Contact information
Practice address
1160 S GRAND AVE, GLENDORA, CA 91740-5000
(626) 335-5980
Mailing address
851 S SUNSET AVE, APT 186, WEST COVINA, CA 91790-5510
(626) 234-6348
Taxonomy
Speciality
Code
Description
License number
State
167G00000X
Licensed Psychiatric Technician
Primary
PT 36343
CA
Other
Enumeration date
04/13/2012
Last updated
04/13/2012
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