Provider Demographics
NPI:1720644990
Name:GUEVARA, NELSON
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:
Last Name:GUEVARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9800 KINCEY AVE STE 160
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-8402
Mailing Address - Country:US
Mailing Address - Phone:980-785-1113
Mailing Address - Fax:
Practice Address - Street 1:9800 KINCEY AVE STE 160
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-8402
Practice Address - Country:US
Practice Address - Phone:980-785-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1-15-04956106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician