Provider Demographics
NPI:1457062689
Name:GUILLEN, GUADALUPE
Entity Type:Individual
Prefix:
First Name:GUADALUPE
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 1:1950 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-1720
Mailing Address - Country:US
Mailing Address - Phone:909-530-5900
Mailing Address - Fax:
Practice Address - Street 1:1950 MARKET ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-1720
Practice Address - Country:US
Practice Address - Phone:909-530-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 171M00000X
CAMPSS-PONYQE175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No175T00000XOther Service ProvidersPeer Specialist