Provider Demographics
NPI:1588302046
Name:FERNANDEZ GUEVARA, EMMA BELEN
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:BELEN
Last Name:FERNANDEZ GUEVARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:253 LAKE ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:VT
Mailing Address - Zip Code:05478-2377
Mailing Address - Country:US
Mailing Address - Phone:802-952-3711
Mailing Address - Fax:
Practice Address - Street 1:4750 COLLEGIATE DR BLDG 157
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-1000
Practice Address - Country:US
Practice Address - Phone:850-770-2241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORBT-21-167366106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician