Healthcare Provider Details

I. General information

NPI: 1235790601
Provider Name (Legal Business Name): GONZALO GUERRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 HOSPITAL DR STE 106
GLEN BURNIE MD
21061-5806
US

IV. Provider business mailing address

325 HOSPITAL DR STE 106
GLEN BURNIE MD
21061-5806
US

V. Phone/Fax

Practice location:
  • Phone: 443-430-2998
  • Fax: 443-431-8978
Mailing address:
  • Phone: 443-430-2998
  • Fax: 443-431-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGP15567
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: