Healthcare Provider Details

I. General information

NPI: 1275854879
Provider Name (Legal Business Name): FERNANDO JOSE GUTIERREZ ED.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 11/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 E DEL MAR BLVD 11A
PASADENA CA
91107-4321
US

IV. Provider business mailing address

PO BOX 70160
PASADENA CA
91117-7160
US

V. Phone/Fax

Practice location:
  • Phone: 818-457-0376
  • Fax: 818-824-3442
Mailing address:
  • Phone: 818-457-0376
  • Fax: 818-824-3442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY8801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: