Basic Information
| Provider Information | |||||||||
| NPI: | 1184155467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUZMAN | ||||||||
| FirstName: | ROSALVA | ||||||||
| MiddleName: | PONCE | ||||||||
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| OtherLastName: | PONCE | ||||||||
| OtherFirstName: | ROSALVA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 501 RIVERGATE WAY APT 105 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958313315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168933413 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2750 SUTTERVILLE RD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958201024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164927240 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2017 | ||||||||
| LastUpdateDate: | 09/26/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.