Provider Demographics
NPI:1598395261
Name:GARZA, JUANITA ALICIA
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:ALICIA
Last Name:GARZA
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 1:648 E 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENNS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83623-2850
Mailing Address - Country:US
Mailing Address - Phone:208-590-5571
Mailing Address - Fax:
Practice Address - Street 1:648 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:GLENNS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83623-2850
Practice Address - Country:US
Practice Address - Phone:208-590-5571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician