Provider Demographics
NPI:1700370202
Name:GUARD, BRENT LAWRENCE
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:LAWRENCE
Last Name:GUARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:LARSEN BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99624-0127
Mailing Address - Country:US
Mailing Address - Phone:907-486-1386
Mailing Address - Fax:907-847-2264
Practice Address - Street 1:3449 E REZANOF DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6952
Practice Address - Country:US
Practice Address - Phone:907-486-1386
Practice Address - Fax:907-847-2264
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK18-135-BHA1101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor