Provider Demographics
NPI:1083223945
Name:GUERRA HURTADO, CRISTIAN ARIEL
Entity Type:Individual
Prefix:
First Name:CRISTIAN
Middle Name:ARIEL
Last Name:GUERRA HURTADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29946 SW 158TH PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-3467
Mailing Address - Country:US
Mailing Address - Phone:786-299-7693
Mailing Address - Fax:
Practice Address - Street 1:14329 SW 168TH TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-2072
Practice Address - Country:US
Practice Address - Phone:786-299-7693
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG663-101-01-041-0Medicaid
FLRBT-20-126802Medicaid