Healthcare Provider Details

I. General information

NPI: 1982282166
Provider Name (Legal Business Name): MIRNA GRISELDA GUTIERREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12235 BEACH BLVD STE 110
STANTON CA
90680-3943
US

IV. Provider business mailing address

11002 GARDEN DR
GARDEN GROVE CA
92840-1034
US

V. Phone/Fax

Practice location:
  • Phone: 714-202-0118
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: