Provider Demographics
NPI:1114382611
Name:GUAJARDO, JUAN ANTONIO
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:ANTONIO
Last Name:GUAJARDO
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 1:1114 N ALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:TX
Mailing Address - Zip Code:78573-1030
Mailing Address - Country:US
Mailing Address - Phone:956-600-6736
Mailing Address - Fax:956-391-2880
Practice Address - Street 1:1114 N ALTON BLVD
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:TX
Practice Address - Zip Code:78573-1030
Practice Address - Country:US
Practice Address - Phone:956-600-6736
Practice Address - Fax:956-391-2880
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69757101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional