Healthcare Provider Details

I. General information

NPI: 1033435813
Provider Name (Legal Business Name): SANDRA YEZENIA GUTIERREZ PHD EDD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2010
Last Update Date: 03/26/2026
Certification Date: 03/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W LAS CRUCES AVE
LAS CRUCES NM
88005-1804
US

IV. Provider business mailing address

PO BOX 1254
HATCH NM
87937-1254
US

V. Phone/Fax

Practice location:
  • Phone: 575-222-2922
  • Fax:
Mailing address:
  • Phone: 575-222-2922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW.09925377
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberX-06821
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-08241
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: