=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205604931
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GUIONS PROFESSIONAL SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2023
-----------------------------------------------------
Last Update Date | 12/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 721 BALMORAL CIR
-----------------------------------------------------
City | LEESBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34748-5606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-435-7068
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1502 N DONNELLY ST STE 109
-----------------------------------------------------
City | MOUNT DORA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32757-2846
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-720-3160
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAID WAIVER PROVIDER
-----------------------------------------------------
Name | MR. TERENCE MICHAEL GUIONS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-800-9589
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------