Provider Demographics
NPI:1508441353
Name:DE GUZMAN, TIQUILA
Entity Type:Individual
Prefix:
First Name:TIQUILA
Middle Name:
Last Name:DE GUZMAN
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 1:7261 W CHARLESTON BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-1679
Mailing Address - Country:US
Mailing Address - Phone:725-251-2059
Mailing Address - Fax:
Practice Address - Street 1:7261 W CHARLESTON BLVD STE 101
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-1679
Practice Address - Country:US
Practice Address - Phone:725-251-2059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVRBT-21-159602106S00000X
NV106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician