Healthcare Provider Details

I. General information

NPI: 1285539304
Provider Name (Legal Business Name): BRIAN SANTIAGO GUZMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047 VISTA PARK DR STE A
FOREST VA
24551-4362
US

IV. Provider business mailing address

PO BOX 3351
LYNCHBURG VA
24503-0351
US

V. Phone/Fax

Practice location:
  • Phone: 434-382-1123
  • Fax:
Mailing address:
  • Phone: 434-509-6407
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0704018800
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: