1578990909 NPI number — ANNE THERESE LOUISE DE GUZMAN LMFT

Table of content: ANNE THERESE LOUISE DE GUZMAN LMFT (NPI 1578990909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578990909 NPI number — ANNE THERESE LOUISE DE GUZMAN LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DE GUZMAN
Provider First Name:
ANNE THERESE
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578990909
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 COLUMBUS AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06519-1233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-503-3174
Provider Business Mailing Address Fax Number:
203-503-3183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
285 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06516-7307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-503-3409
Provider Business Practice Location Address Fax Number:
203-503-3414
Provider Enumeration Date:
09/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  1734 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004235918 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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