Healthcare Provider Details

I. General information

NPI: 1639566953
Provider Name (Legal Business Name): JOHN GUTIERREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2015
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3281 LEDGEWOOD CIRCLE
RIVERSIDE CA
92503
US

IV. Provider business mailing address

3281 LEDGEWOOD CIRCLE
RIVERSIDE CA
92503
US

V. Phone/Fax

Practice location:
  • Phone: 909-702-5413
  • Fax:
Mailing address:
  • Phone: 909-702-5413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number833543
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: