Provider Demographics
NPI:1023272705
Name:DE GUZMAN, AILEEN GRACE FORTICH (OTR)
Entity type:Individual
Prefix:
First Name:AILEEN GRACE
Middle Name:FORTICH
Last Name:DE GUZMAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26918 REDSTONE HILL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261
Mailing Address - Country:US
Mailing Address - Phone:830-438-5955
Mailing Address - Fax:
Practice Address - Street 1:3290 N RIDGE RD
Practice Address - Street 2:SUITE 290
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21043-3655
Practice Address - Country:US
Practice Address - Phone:210-473-9142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-11
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX112731225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist