Healthcare Provider Details

I. General information

NPI: 1366952962
Provider Name (Legal Business Name): ISMAEL L DE GUZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2017
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2665 5TH ST
ALAMEDA CA
94501-6514
US

IV. Provider business mailing address

1801 VICENTE ST
SAN FRANCISCO CA
94116-2923
US

V. Phone/Fax

Practice location:
  • Phone: 415-407-2057
  • Fax:
Mailing address:
  • Phone: 415-681-3211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number106304
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: