Provider Demographics
NPI:1437596822
Name:DE GUZMAN, MARC DWIGHT
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:DWIGHT
Last Name:DE GUZMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 VALLERAND RD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-2442
Mailing Address - Country:US
Mailing Address - Phone:650-766-4474
Mailing Address - Fax:
Practice Address - Street 1:755 S VAN NESS AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-1908
Practice Address - Country:US
Practice Address - Phone:415-642-4552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-27
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 172V00000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health