Healthcare Provider Details

I. General information

NPI: 1225477037
Provider Name (Legal Business Name): JOHANNA CUELLO-GUTIERREZ LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2013
Last Update Date: 06/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4419 3RD AVE
BRONX NY
10457-2562
US

IV. Provider business mailing address

4419 3RD AVE
BRONX NY
10457-2562
US

V. Phone/Fax

Practice location:
  • Phone: 718-364-7700
  • Fax: 718-364-1513
Mailing address:
  • Phone: 718-364-7700
  • Fax: 718-364-1513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number005262
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: