Provider Demographics
NPI:1669226056
Name:GUZMAN ROMAN, JOHANNY LICELOT
Entity type:Individual
Prefix:
First Name:JOHANNY
Middle Name:LICELOT
Last Name:GUZMAN ROMAN
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 1:5865 CARIBBEAN BLVD APT 4305
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33407-1797
Mailing Address - Country:US
Mailing Address - Phone:561-507-4636
Mailing Address - Fax:
Practice Address - Street 1:5865 CARIBBEAN BLVD APT 4305
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-1797
Practice Address - Country:US
Practice Address - Phone:561-507-4636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-339888106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician