Healthcare Provider Details

I. General information

NPI: 1093376741
Provider Name (Legal Business Name): LUIS GUILLERMO HUERTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2019
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64 E WELDON AVE
FRESNO CA
93704-5956
US

IV. Provider business mailing address

5325 N FRESNO ST STE 106
FRESNO CA
93710-6849
US

V. Phone/Fax

Practice location:
  • Phone: 559-442-1947
  • Fax:
Mailing address:
  • Phone: 877-418-2978
  • Fax: 866-500-2186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: