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General NPI Number Information
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NPI Number | 1104257807
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Entity Type | Organization
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Legal Business Name | MARCIO GUZMAN
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Dates
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Enumeration Date | 12/05/2013
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Last Update Date | 12/05/2013
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Provider Practice Location Address
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Address Line | 1855 BOWLES AVE SUITE 210
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City | FENTON
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State | MO
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Zip | 63026-1900
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Country | US
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Telephone | 630-991-8315
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Fax |
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Provider Business Mailing Address
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Address Line | 7746 DELMAR BLVD APT 1F
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City | SAINT LOUIS
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State | MO
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Zip | 63130-3917
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PSYCHOTHERAPIST
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Name | MARCIO GUZMAN
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Credential |
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Telephone | 630-991-8315
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | 2013005503
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License Number State | MO
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