Healthcare Provider Details

I. General information

NPI: 1457962557
Provider Name (Legal Business Name): GREYSON C GUZMAN RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12125 SHALE RIDGE LN
AUBURN CA
95602-8880
US

IV. Provider business mailing address

12125 SHALE RIDGE LN
AUBURN CA
95602-8880
US

V. Phone/Fax

Practice location:
  • Phone: 530-885-1917
  • Fax:
Mailing address:
  • Phone: 530-885-1917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1391180520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: