Healthcare Provider Details

I. General information

NPI: 1467653485
Provider Name (Legal Business Name): GUILLERMO A REGALADO MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23621 MAIN ST
CARSON CA
90745-5743
US

IV. Provider business mailing address

2228 STONEWOOD CT
SAN PEDRO CA
90732-1337
US

V. Phone/Fax

Practice location:
  • Phone: 310-816-5356
  • Fax:
Mailing address:
  • Phone: 310-251-5516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number39061
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: