Basic Information
| Provider Information | |||||||||
| NPI: | 1003319971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUZMAN | ||||||||
| FirstName: | DIANA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1402 ROYAL PALM BEACH BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | ROYAL PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334115001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616297897 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1402 ROYAL PALM BEACH BLVD STE 102 | ||||||||
| Address2: | |||||||||
| City: | ROYAL PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334115001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616297897 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2018 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | MCAP100136 | FL | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | IMH15395 | FL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | MH19283 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | MH19283 | 01 | FL | LICENSE | OTHER |