Provider Demographics
NPI:1740795582
Name:GUAJARDO, CAROLYN MARIE (MA, LAC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:GUAJARDO
Suffix:
Gender:F
Credentials:MA, LAC
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:MARIE
Other - Last Name:EHAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4633 N 1ST AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-8605
Mailing Address - Country:US
Mailing Address - Phone:520-260-7990
Mailing Address - Fax:
Practice Address - Street 1:4633 N 1ST AVE STE 2
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-8605
Practice Address - Country:US
Practice Address - Phone:520-260-7990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-01
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC15778101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional