Provider Demographics
NPI:1881211696
Name:GUZMAN, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:GUZMAN
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 1:1000 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7667
Mailing Address - Country:US
Mailing Address - Phone:541-500-0977
Mailing Address - Fax:
Practice Address - Street 1:900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7136
Practice Address - Country:US
Practice Address - Phone:541-500-0977
Practice Address - Fax:541-842-7640
Is Sole Proprietor?:No
Enumeration Date:2020-06-26
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORR7107101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health