Provider Demographics
NPI:1417113622
Name:GUANZON, RAFAEL MADAYAG (OTR)
Entity Type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:MADAYAG
Last Name:GUANZON
Suffix:
Gender:M
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 SCENIC VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-7967
Mailing Address - Country:US
Mailing Address - Phone:219-462-8308
Mailing Address - Fax:
Practice Address - Street 1:6685 E 117TH AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7808
Practice Address - Country:US
Practice Address - Phone:219-663-6392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004394A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist