Provider Demographics
NPI:1992194518
Name:GUILLEN, YELITZA
Entity Type:Individual
Prefix:
First Name:YELITZA
Middle Name:
Last Name:GUILLEN
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 1:6595 NW 36TH ST
Mailing Address - Street 2:SUITE 101-D
Mailing Address - City:VIRGINIA GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33166-6979
Mailing Address - Country:US
Mailing Address - Phone:786-345-1508
Mailing Address - Fax:
Practice Address - Street 1:7925 NW 12TH ST STE 225
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1821
Practice Address - Country:US
Practice Address - Phone:305-456-4378
Practice Address - Fax:305-846-9490
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-20
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCMS0101128104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111056600Medicaid