Healthcare Provider Details

I. General information

NPI: 1649347949
Provider Name (Legal Business Name): GERSON GUZMAN MS, CCC-SLP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 MONTANA AVE
DAVENPORT FL
33897-5641
US

IV. Provider business mailing address

604 MONTANA AVE
DAVENPORT FL
33897-5641
US

V. Phone/Fax

Practice location:
  • Phone: 407-922-6656
  • Fax: 863-438-5271
Mailing address:
  • Phone: 407-922-6656
  • Fax: 863-438-5271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA 6430
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: