Healthcare Provider Details

I. General information

NPI: 1114453974
Provider Name (Legal Business Name): OMAR GUZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5958 S MARSHFIELD AVE
CHICAGO IL
60636-1742
US

IV. Provider business mailing address

5145 S HARDING AVE
CHICAGO IL
60632-3710
US

V. Phone/Fax

Practice location:
  • Phone: 773-964-8501
  • Fax:
Mailing address:
  • Phone: 773-964-8501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149-019421
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: