{
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"FirstLineMailingAddress": "1264 N CHALAN CANTON TASI",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "YONA",
"MailingAddressStateName": "GU",
"MailingAddressPostalCode": "96915-4644",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "671-777-3764",
"MailingAddressFaxNumber": "671-472-5450",
"FirstLinePracticeLocationAddress": "1264 N CHALAN CANTON TASI",
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"PracticeLocationAddressCityName": "YONA",
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"PracticeLocationAddressTelephoneNumber": "671-777-3764",
"PracticeLocationAddressFaxNumber": "671-472-5450",
"EnumerationDate": "04/28/2013",
"LastUpdateDate": "04/28/2013",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
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"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "BAZA",
"AuthorizedOfficialFirstName": "LISA",
"AuthorizedOfficialMiddleName": "VILLANUEVA",
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"AuthorizedOfficialCredential": "M.A.",
"AuthorizedOfficialTelephoneNumber": "671-777-3764",
"Taxonomies": {
"Taxonomy": {
"TaxonomyCode": "101YM0800X",
"TaxonomyName": "Mental Health Counselor",
"LicenseNumber": "IMF-76",
"LicenseNumberStateCode": "GU",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": {
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"HealthcareProviderTaxonomyGroupDescription": "Single Specialty Group - A business group of one or more individual practitioners, all of who practice with the same area of specialization."
}
}
}
}