Healthcare Provider Details

I. General information

NPI: 1093417362
Provider Name (Legal Business Name): MARIA ELENA GUZMAN AYALA SUDRC-18013
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17822 BEACH BLVD STE 278
HUNTINGTON BEACH CA
92647-7180
US

IV. Provider business mailing address

17822 BEACH BLVD STE 278
HUNTINGTON BEACH CA
92647-7180
US

V. Phone/Fax

Practice location:
  • Phone: 714-375-3795
  • Fax: 714-375-3796
Mailing address:
  • Phone: 714-375-3795
  • Fax: 714-375-3796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSUDRC-18013
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: