Provider Demographics
NPI:1679615439
Name:GUILLERMO, CARMEN R (MA (MASTER OF ARTS)
Entity Type:Individual
Prefix:MS
First Name:CARMEN
Middle Name:R
Last Name:GUILLERMO
Suffix:
Gender:F
Credentials:MA (MASTER OF ARTS
Other - Prefix:MRS
Other - First Name:CARMEN
Other - Middle Name:RODRIGUEZ
Other - Last Name:NEWLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA (MASTER OF ARTS
Mailing Address - Street 1:1204 COTTONWOOD ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-4362
Mailing Address - Country:US
Mailing Address - Phone:530-668-1663
Mailing Address - Fax:530-668-8150
Practice Address - Street 1:1204 COTTONWOOD ST
Practice Address - Street 2:SUITE 6
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-4362
Practice Address - Country:US
Practice Address - Phone:530-668-1663
Practice Address - Fax:530-668-8150
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU310 AND HA3045237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0003100Medicaid
CAHA0030450Medicaid
CAAU0003100Medicare UPIN
CAHA0030450Medicaid