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: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | CP000022 | GU | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical | 103TC0700X | PSY705 | HI | N | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.