Provider Demographics
NPI:1164151312
Name:GUAJARDO, THALIA CELESTE
Entity Type:Individual
Prefix:MS
First Name:THALIA
Middle Name:CELESTE
Last Name:GUAJARDO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 17TH ST APT 104
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-6395
Mailing Address - Country:US
Mailing Address - Phone:208-286-5366
Mailing Address - Fax:
Practice Address - Street 1:2704 17TH ST APT 104
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-6395
Practice Address - Country:US
Practice Address - Phone:208-286-5366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-05
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer