Basic Information
| Provider Information | |||||||||
| NPI: | 1710521794 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VARGAS | ||||||||
| FirstName: | GUADALUPE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14206 GALVIN CT | ||||||||
| Address2: | |||||||||
| City: | MORENO VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925533997 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7143929338 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15405 LANSDOWNE RD STE C | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927820201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7142587710 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2019 | ||||||||
| LastUpdateDate: | 07/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.