Basic Information
| Provider Information | |||||||||
| NPI: | 1861938557 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUERRERO | ||||||||
| FirstName: | SHIZATIZ | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 23701 E EAST FORK RD | ||||||||
| Address2: | |||||||||
| City: | AZUSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917021477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262503291 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9500 HAVEN AVE | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099806700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2017 | ||||||||
| LastUpdateDate: | 09/06/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 07/24/2018 | ||||||||
| NPIReactivationDate: | 08/15/2018 | ||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101YM0800X | 84252 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.