Basic Information
Provider Information
NPI: 1003000761
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TAIMANGLO
FirstName: PATRICIA
MiddleName: LEON GUERRERO
NamePrefix: MS.
NameSuffix:  
Credential: PHD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName: PIER
OtherFirstName: PATRICIA
OtherMiddleName: TAIMANGLO
OtherNamePrefix: MS.
OtherNameSuffix:  
OtherCredential: PHD
OtherLastNameType: 1
Mailing Information
Address1: 590 S MARINE CORPS DRIVE
Address2: SUITE 219 GITC BLDG
City: TAMUNING
State: GU
PostalCode: 96914
CountryCode: US
TelephoneNumber: 6716492080
FaxNumber: 6716492082
Practice Location
Address1: 590 S MARINE CORPS DRIVE
Address2: SUITE 219 GITC BLDG
City: TAMUNING
State: GU
PostalCode: 96913
CountryCode: US
TelephoneNumber: 6716492080
FaxNumber: 6716492083
Other Information
ProviderEnumerationDate: 09/05/2007
LastUpdateDate: 09/05/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC0700XPSY705HIN Behavioral Health & Social Service ProvidersPsychologistClinical
103TC0700XCP000022GUY Behavioral Health & Social Service ProvidersPsychologistClinical

No ID Information.


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