Healthcare Provider Details

I. General information

NPI: 1265024889
Provider Name (Legal Business Name): MARIE A GUTIERREZ-DIAZ MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIE A GUTIERREZ-DIAZ MSW

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 02/04/2021
Certification Date: 02/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 LOS LENTES RD SE # 3
LOS LUNAS NM
87031-6018
US

IV. Provider business mailing address

81 STOREY AVE
BELEN NM
87002-9203
US

V. Phone/Fax

Practice location:
  • Phone: 505-865-3350
  • Fax:
Mailing address:
  • Phone: 505-388-4925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberM-11450
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: