Healthcare Provider Details

I. General information

NPI: 1346382215
Provider Name (Legal Business Name): IDA G GUTIERREZ MPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 09/07/2020
Certification Date: 09/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7109 N BARTLETT AVE STE 109
LAREDO TX
78041-6473
US

IV. Provider business mailing address

7109 N BARTLETT AVE STE 109
LAREDO TX
78041-6473
US

V. Phone/Fax

Practice location:
  • Phone: 956-727-2122
  • Fax: 956-727-4445
Mailing address:
  • Phone: 956-727-2122
  • Fax: 956-727-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1114338
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: