Provider Demographics
NPI:1932364742
Name:GUILLEN, KATHLEEN JO (MC)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:JO
Last Name:GUILLEN
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 W. SEED FARM RD.
Mailing Address - Street 2:NEW BEGINNINGS BUILDING
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85247
Mailing Address - Country:US
Mailing Address - Phone:602-528-7179
Mailing Address - Fax:602-528-1374
Practice Address - Street 1:483 W. SEED FARM RD.
Practice Address - Street 2:NEW BEGINNINGS BUILDING
Practice Address - City:SACATON
Practice Address - State:AZ
Practice Address - Zip Code:85247
Practice Address - Country:US
Practice Address - Phone:602-528-7179
Practice Address - Fax:602-528-1374
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLAC12771101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ326214Medicaid