Provider Demographics
NPI:1821474321
Name:ANGEL, LOURDES DE GUZMAN
Entity Type:Individual
Prefix:
First Name:LOURDES
Middle Name:DE GUZMAN
Last Name:ANGEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LOURDES
Other - Middle Name:CARANTO
Other - Last Name:DE GUZMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2495 W MARCH LN STE 125
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-8224
Mailing Address - Country:US
Mailing Address - Phone:209-465-1080
Mailing Address - Fax:
Practice Address - Street 1:2495 W MARCH LN STE 125
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8224
Practice Address - Country:US
Practice Address - Phone:209-465-1080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141126164X00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No164X00000XNursing Service ProvidersLicensed Vocational Nurse