Healthcare Provider Details

I. General information

NPI: 1831379064
Provider Name (Legal Business Name): JOSE L. GUTIERREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S DE LACEY AVE
PASADENA CA
91105-2048
US

IV. Provider business mailing address

210 S DE LACEY AVE
PASADENA CA
91105-2048
US

V. Phone/Fax

Practice location:
  • Phone: 626-395-7100
  • Fax:
Mailing address:
  • Phone: 626-395-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF98354
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: