Healthcare Provider Details

I. General information

NPI: 1689097941
Provider Name (Legal Business Name): STEPHANIE GUTZ, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 GUSDORF RD SUITE E
TAOS NM
87571-5402
US

IV. Provider business mailing address

PO BOX 1077
EL PRADO NM
87529-1077
US

V. Phone/Fax

Practice location:
  • Phone: 575-779-3391
  • Fax:
Mailing address:
  • Phone: 575-779-3391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI-06602
License Number StateNM

VIII. Authorized Official

Name: MS. STEPHANIE GUTZ
Title or Position: PRESIDENT
Credential:
Phone: 575-779-3391