Healthcare Provider Details

I. General information

NPI: 1073164133
Provider Name (Legal Business Name): DAVID ALFONSO GUZMAN LPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 FAIR OAKS AVE STE 300
S PASADENA CA
91030-5805
US

IV. Provider business mailing address

625 FAIR OAKS AVE
S PASADENA CA
91030-2630
US

V. Phone/Fax

Practice location:
  • Phone: 626-723-9438
  • Fax:
Mailing address:
  • Phone: 626-723-9438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number41317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: