Healthcare Provider Details

I. General information

NPI: 1386269025
Provider Name (Legal Business Name): MINDY GUTOW PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 06/09/2020
Certification Date: 06/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7013 RIO GRANDE BLVD NW
LOS RANCHOS NM
87107-6423
US

IV. Provider business mailing address

7013 RIO GRANDE BLVD NW
LOS RANCHOS NM
87107-6423
US

V. Phone/Fax

Practice location:
  • Phone: 505-398-3624
  • Fax:
Mailing address:
  • Phone: 505-398-3624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0936
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number0936
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: