Healthcare Provider Details

I. General information

NPI: 1396381646
Provider Name (Legal Business Name): CORI GUEVARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2019
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1934 OLD GALLOWS RD STE 360
VIENNA VA
22182-4040
US

IV. Provider business mailing address

901 WASHINGTON AVE STE 100
PORTLAND ME
04103-2842
US

V. Phone/Fax

Practice location:
  • Phone: 703-752-6181
  • Fax:
Mailing address:
  • Phone: 207-871-1200
  • Fax: 207-871-1232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberXL5336
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701012547
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: