Provider Demographics
NPI:1730655176
Name:GUEVARA, GLADYS CECELIA (RADT I)
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:CECELIA
Last Name:GUEVARA
Suffix:
Gender:F
Credentials:RADT I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1302 RIALTO AVE
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-2433
Mailing Address - Country:US
Mailing Address - Phone:909-835-7482
Mailing Address - Fax:
Practice Address - Street 1:1330 W RAMSEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-4477
Practice Address - Country:US
Practice Address - Phone:951-849-7142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14699101YA0400X
CAR1490871122101YA0400X
106S00000X, 171M00000X
CA251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00051147OtherCPT 1
CA14699-IOtherREGISTERED ADDICTION COUNSELOR