Basic Information
| Provider Information | |||||||||
| NPI: | 1003041682 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUERRA | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., LLPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104550102 | ||||||||
| FaxNumber: | 8109848896 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 SUPERIOR ST | ||||||||
| Address2: | |||||||||
| City: | PORT HURON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480603838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104550102 | ||||||||
| FaxNumber: | 8109848896 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2009 | ||||||||
| LastUpdateDate: | 05/26/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401009438 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 101464 | 05 | MI | MEDICAID |