Provider Demographics
NPI:1376107649
Name:GUILLEN, LORRAINE
Entity Type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:GUILLEN
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 1:715 E IDAHO AVE STE 2B
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-4701
Mailing Address - Country:US
Mailing Address - Phone:575-556-9585
Mailing Address - Fax:575-556-9456
Practice Address - Street 1:715 E IDAHO AVE STE 2B
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-4701
Practice Address - Country:US
Practice Address - Phone:575-556-9585
Practice Address - Fax:575-556-9456
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMC-074561041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical