Healthcare Provider Details

I. General information

NPI: 1548764145
Provider Name (Legal Business Name): RAYMOND J GUAJARDO LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2018
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17606 COSHOCTON RD
MOUNT VERNON OH
43050-9218
US

IV. Provider business mailing address

2000 NOBLE DR
WOOSTER OH
44691-5353
US

V. Phone/Fax

Practice location:
  • Phone: 740-397-7568
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.2208311
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: