Healthcare Provider Details

I. General information

NPI: 1780491050
Provider Name (Legal Business Name): MRS. ALICIA GUTIERREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 EUBANKS RD
COMBINE TX
75159-6040
US

IV. Provider business mailing address

700 EUBANKS RD
COMBINE TX
75159-6040
US

V. Phone/Fax

Practice location:
  • Phone: 469-865-5720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number95009
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number000000
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: