Provider Demographics
NPI:1093527160
Name:GUILLEN GARCIA, DOUGLAS LAZARO
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:LAZARO
Last Name:GUILLEN GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 36TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33976-4671
Mailing Address - Country:US
Mailing Address - Phone:239-248-4812
Mailing Address - Fax:
Practice Address - Street 1:12651 MCGREGOR BLVD STE 501
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4496
Practice Address - Country:US
Practice Address - Phone:239-691-6482
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-397510106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician