Healthcare Provider Details

I. General information

NPI: 1639870934
Provider Name (Legal Business Name): NICOLE MARIE GUTIERREZ RIVERA MASTER DEGREE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 CASIA STREET
SAN JUAN PR
00921-3201
US

IV. Provider business mailing address

328 CALLE SAN MATEO
JUNCOS PR
00777-8634
US

V. Phone/Fax

Practice location:
  • Phone: 787-641-7582
  • Fax:
Mailing address:
  • Phone: 787-478-9314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number16188
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: