Provider Demographics
NPI:1558694125
Name:GUZMAN, ERIC TABAMO (MS, MFT)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:TABAMO
Last Name:GUZMAN
Suffix:
Gender:M
Credentials:MS, MFT
Other - Prefix:MR
Other - First Name:ERIC
Other - Middle Name:TABAMO
Other - Last Name:GUZMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, MFT
Mailing Address - Street 1:324 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1946
Mailing Address - Country:US
Mailing Address - Phone:608-617-4173
Mailing Address - Fax:
Practice Address - Street 1:2009 5TH ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WI
Practice Address - Zip Code:53566-1546
Practice Address - Country:US
Practice Address - Phone:608-324-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI974-124106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1558694125Medicaid