Provider Demographics
NPI:1710720016
Name:GUSMAN, ENRIQUE HUMBERTO (SUDRC)
Entity type:Individual
Prefix:
First Name:ENRIQUE
Middle Name:HUMBERTO
Last Name:GUSMAN
Suffix:
Gender:M
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 N ORANGE DR APT 208
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90038-1096
Mailing Address - Country:US
Mailing Address - Phone:323-445-0011
Mailing Address - Fax:
Practice Address - Street 1:1227 N ORANGE DR APT 208
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90038-1096
Practice Address - Country:US
Practice Address - Phone:323-445-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-14
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13632101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)