Healthcare Provider Details

I. General information

NPI: 1578294732
Provider Name (Legal Business Name): CHRISTIAN BENJAMIN CABEZAS GUERRA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2022
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

797 7TH ST E
SAINT PAUL MN
55106-5070
US

IV. Provider business mailing address

11496 SANDCASTLE DR
WOODBURY MN
55129-5017
US

V. Phone/Fax

Practice location:
  • Phone: 651-379-4200
  • Fax:
Mailing address:
  • Phone: 763-370-1282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number306384
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: