Basic Information
| Provider Information | |||||||||
| NPI: | 1124142435 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DE GUZMAN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HO | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2011 | ||||||||
| Address2: | |||||||||
| City: | CANYON COUNTRY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913862011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
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| Practice Location | |||||||||
| Address1: | 19401 S VERMONT AVE | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905021029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103236887 | ||||||||
| FaxNumber: | 3103231570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 1041C0700X | 73683 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.