Healthcare Provider Details

I. General information

NPI: 1548342686
Provider Name (Legal Business Name): JUAN J GUTIERREZ MSW,LISW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

01 SAGEBRUSH
ISLETA NM
87022-0000
US

IV. Provider business mailing address

PO BOX 640
ISLETA NM
87022-0640
US

V. Phone/Fax

Practice location:
  • Phone: 505-869-4863
  • Fax: 505-869-4881
Mailing address:
  • Phone: 505-869-4863
  • Fax: 505-869-4881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-1552
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: