Provider Demographics
NPI:1215417555
Name:GUZMAN, ILYSSA KRISTINE (COTA)
Entity Type:Individual
Prefix:MISS
First Name:ILYSSA
Middle Name:KRISTINE
Last Name:GUZMAN
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8716 PUERTO BELO
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-6218
Mailing Address - Country:US
Mailing Address - Phone:956-652-7020
Mailing Address - Fax:
Practice Address - Street 1:1419 CORPUS CHRISTI ST
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78040-5358
Practice Address - Country:US
Practice Address - Phone:956-723-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX215112224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant