Provider Demographics
NPI:1063680940
Name:GUAJARDO, TERESA MARIE (MA, LMP, LMHC)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:GUAJARDO
Suffix:
Gender:F
Credentials:MA, LMP, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:509 12TH AVE SE
Mailing Address - Street 2:SUITE 20
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-7514
Mailing Address - Country:US
Mailing Address - Phone:360-789-7025
Mailing Address - Fax:360-357-3080
Practice Address - Street 1:509 12TH AVE SE
Practice Address - Street 2:SUITE 20
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-7514
Practice Address - Country:US
Practice Address - Phone:360-789-7025
Practice Address - Fax:360-357-3080
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH60173201101YM0800X
WAMA00015038225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0151447OtherLABOR AND INDUSTRIES
WA2950925OtherCOMMUNITY HEALTH PLAN OF
WA9841519OtherCRIME VICTIMS COMPENSATIO
WA8943959OtherCRIME VICTIMS COMPENSATIO