MEDICARE: KRYSTAL GUTIERREZ-AVILA LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	8235-C	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699140921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL GUTIERREZ-AVILA LCSW

Provider Business Mailing Address
First Line	:	3325 RESEARCH WAY
Second Line	:
City	:	CARSON CITY
State	:	NV
Zip	:	89706-7913
Country	:	US
Telephone Number	:	775-888-6610
Fax Number	:	775-888-4904

Provider Business Practice Location Address
First Line	:	98 E LAKE MEAD PKWY STE 103
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89015-6443
Country	:	US
Telephone Number	:	702-868-0327
Fax Number	:	702-868-0290

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/11/2015
Last Update Date	:	04/03/2020

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