Healthcare Provider Details

I. General information

NPI: 1366723769
Provider Name (Legal Business Name): MELISSA GUTIERREZ PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 11/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 UNIVERSITY COMMONS SUITE 430
SOUTH BEND IN
46635-1571
US

IV. Provider business mailing address

6301 UNIVERSITY COMMONS SUITE 430
SOUTH BEND IN
46635-1571
US

V. Phone/Fax

Practice location:
  • Phone: 574-968-2851
  • Fax: 574-968-2855
Mailing address:
  • Phone: 574-968-2851
  • Fax: 574-968-2855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01050166A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: