Provider Demographics
NPI:1942699699
Name:DE GUZMAN, AGNES (PT)
Entity Type:Individual
Prefix:MISS
First Name:AGNES
Middle Name:
Last Name:DE GUZMAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17412 BLACKHAWK ST
Mailing Address - Street 2:
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344-6036
Mailing Address - Country:US
Mailing Address - Phone:707-342-4716
Mailing Address - Fax:
Practice Address - Street 1:17412 BLACKHAWK ST
Practice Address - Street 2:
Practice Address - City:GRANADA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91344-6036
Practice Address - Country:US
Practice Address - Phone:707-342-4716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36781225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist