Healthcare Provider Details

I. General information

NPI: 1598814840
Provider Name (Legal Business Name): STACY MARIE GUTIERREZ A.T.,C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14349 LEROY ST
SOUTHGATE MI
48195-2066
US

IV. Provider business mailing address

14349 LEROY ST
SOUTHGATE MI
48195-2066
US

V. Phone/Fax

Practice location:
  • Phone: 313-657-3675
  • Fax:
Mailing address:
  • Phone: 313-657-3675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: