Provider Demographics
NPI:1821548173
Name:GUILLORY, CHRISTIAN
Entity Type:Individual
Prefix:MS
First Name:CHRISTIAN
Middle Name:
Last Name:GUILLORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12755 N HIGHWAY 88
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-9323
Mailing Address - Country:US
Mailing Address - Phone:209-340-5820
Mailing Address - Fax:
Practice Address - Street 1:12755 N HIGHWAY 88
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-9323
Practice Address - Country:US
Practice Address - Phone:209-340-5820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1861551715Medicaid