Healthcare Provider Details

I. General information

NPI: 1659508844
Provider Name (Legal Business Name): JOHN GUTIERREZ LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 07/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 E BROADWAY ROAD
APACHE JUNCTION AZ
85219
US

IV. Provider business mailing address

PO BOX 3160
APACHE JUNCTION AZ
85217-3160
US

V. Phone/Fax

Practice location:
  • Phone: 480-983-0562
  • Fax: 480-983-0635
Mailing address:
  • Phone: 480-983-0065
  • Fax: 480-983-0635

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0695
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: