Healthcare Provider Details

I. General information

NPI: 1083840615
Provider Name (Legal Business Name): STEPHEN JOSEPH GUTIERREZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2009
Last Update Date: 06/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45439 LIVE OAK DRIVE FISCAL DEPARTMENT
HAMMOND LA
70401
US

IV. Provider business mailing address

45439 LIVE OAK DRIVE FISCAL DEPARTMENT
HAMMOND LA
70401
US

V. Phone/Fax

Practice location:
  • Phone: 225-567-3111
  • Fax: 225-567-2017
Mailing address:
  • Phone: 225-567-3111
  • Fax: 225-567-2017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA200020
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: