Healthcare Provider Details

I. General information

NPI: 1255149035
Provider Name (Legal Business Name): IAN ALEXANDER GUTIERREZ PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2024
Last Update Date: 12/24/2024
Certification Date: 12/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3717 DECATUR AVE
KENSINGTON MD
20895-2148
US

IV. Provider business mailing address

9129 FLAMEPOOL WAY
COLUMBIA MD
21045-2903
US

V. Phone/Fax

Practice location:
  • Phone: 844-361-2273
  • Fax:
Mailing address:
  • Phone: 440-781-5395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number06907
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: