Provider Demographics
NPI:1538265269
Name:GUILLERMO, MARIA-CECILIA
Entity type:Individual
Prefix:
First Name:MARIA-CECILIA
Middle Name:
Last Name:GUILLERMO
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 1:3270 KERNER BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-4840
Mailing Address - Country:US
Mailing Address - Phone:415-473-3270
Mailing Address - Fax:
Practice Address - Street 1:3270 KERNER BLVD STE B
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-4840
Practice Address - Country:US
Practice Address - Phone:415-473-3270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT22935106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
05-1063OtherFQHC MEDICARE PART A
ZZZ29799ZOtherFQHC MEDICARE PART B