Healthcare Provider Details

I. General information

NPI: 1629304043
Provider Name (Legal Business Name): WILFORD GUEVARA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2009
Last Update Date: 10/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 W BROADWAY FL 2
PATERSON NJ
07505-1014
US

IV. Provider business mailing address

222 MADISON AVE
PATERSON NJ
07524-1812
US

V. Phone/Fax

Practice location:
  • Phone: 973-214-0670
  • Fax: 973-684-5788
Mailing address:
  • Phone: 973-214-0670
  • Fax: 973-684-5788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number37PC00110500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number37PC00110500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number37PC00110500
License Number StateNJ
# 4
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number37PC00110500
License Number StateNJ
# 5
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number37PC00110500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: