Healthcare Provider Details

I. General information

NPI: 1912287970
Provider Name (Legal Business Name): EVANGELINA GUTIERREZ LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 08/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66 HURLBUT ST
PASADENA CA
91105-4025
US

IV. Provider business mailing address

2219 MOUNTAIN AVE
DUARTE CA
91010
US

V. Phone/Fax

Practice location:
  • Phone: 626-441-4221
  • Fax: 626-799-1246
Mailing address:
  • Phone: 626-827-3833
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License NumberPT 36097
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: