Healthcare Provider Details

I. General information

NPI: 1700124112
Provider Name (Legal Business Name): JAIME GUERRERO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 02/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 COLORADO AVE SUITE 111
STUART FL
34994-3013
US

IV. Provider business mailing address

5111 SE MILES GRANT RD APT 201
STUART FL
34997-1827
US

V. Phone/Fax

Practice location:
  • Phone: 859-489-8155
  • Fax:
Mailing address:
  • Phone: 859-489-8155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY9449
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: