Provider Demographics
NPI:1528204872
Name:MCGUIRE, GWENDOLYN ROSE
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:ROSE
Last Name:MCGUIRE
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 1:16782 VON KARMAN AVE STE 11
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-2417
Mailing Address - Country:US
Mailing Address - Phone:949-833-2237
Mailing Address - Fax:
Practice Address - Street 1:2928 JEFFERSON ST STE 100
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-2374
Practice Address - Country:US
Practice Address - Phone:760-637-9996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 106S00000X
IL227.012847225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist