Basic Information
| Provider Information | |||||||||
| NPI: | 1427200906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUAJARDO | ||||||||
| FirstName: | VICTOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 69 | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488010069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894634971 | ||||||||
| FaxNumber: | 9894636515 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 E WARWICK DR | ||||||||
| Address2: | |||||||||
| City: | ALMA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488011014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894634971 | ||||||||
| FaxNumber: | 9894636515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2008 | ||||||||
| LastUpdateDate: | 10/16/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401004511 | MI | N | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | 6801015164 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.