Provider Demographics
NPI:1578683637
Name:GUERRA, ANGIE O (COTAL)
Entity Type:Individual
Prefix:MS
First Name:ANGIE
Middle Name:O
Last Name:GUERRA
Suffix:
Gender:F
Credentials:COTAL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 ROBSON ST
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061
Mailing Address - Country:US
Mailing Address - Phone:505-388-5333
Mailing Address - Fax:505-537-3921
Practice Address - Street 1:900 CENTRAL
Practice Address - Street 2:
Practice Address - City:BAYARD
Practice Address - State:NM
Practice Address - Zip Code:88023
Practice Address - Country:US
Practice Address - Phone:505-537-4000
Practice Address - Fax:505-537-3921
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1956224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant