=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891969085
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GUADALUPE I ELIZONDO LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2008
-----------------------------------------------------
Last Update Date | 12/17/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7706 CROOKED ROAD ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78254-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-421-3287
-----------------------------------------------------
Fax | 210-845-1547
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7706 CROOKED ROAD ST
-----------------------------------------------------
City | SAN ANTONIO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78254-2613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 210-421-3287
-----------------------------------------------------
Fax | 210-845-1547
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 12508
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 12508
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------