Healthcare Provider Details

I. General information

NPI: 1740105105
Provider Name (Legal Business Name): MAILLIE FALGOUT GUTIERREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SW F AVE
LAWTON OK
73501-4542
US

IV. Provider business mailing address

502 NW FORT SILL BLVD
LAWTON OK
73507-6604
US

V. Phone/Fax

Practice location:
  • Phone: 580-699-2700
  • Fax:
Mailing address:
  • Phone: 580-699-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-502778
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: