Provider Demographics
NPI:1275782302
Name:HERRERA, GUILLERMO OSVALDO (PHD)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:OSVALDO
Last Name:HERRERA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9345 PIONEER BLVD
Mailing Address - Street 2:#202
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-2387
Mailing Address - Country:US
Mailing Address - Phone:310-601-8170
Mailing Address - Fax:310-693-8012
Practice Address - Street 1:9345 PIONEER BLVD
Practice Address - Street 2:#202
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-2387
Practice Address - Country:US
Practice Address - Phone:310-601-8170
Practice Address - Fax:310-693-8012
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15739103TB0200X, 103TC0700X, 103TC2200X, 103TF0200X, 103TH0004X, 103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY157391OtherMEDI-CAL