Healthcare Provider Details

I. General information

NPI: 1659020097
Provider Name (Legal Business Name): MARIA THERESA BARRERA GUTIERREZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2022
Last Update Date: 10/03/2025
Certification Date: 10/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 MARVELLE LN STE 1
GREEN BAY WI
54304-4683
US

IV. Provider business mailing address

790 MARVELLE LN STE 1
GREEN BAY WI
54304-4683
US

V. Phone/Fax

Practice location:
  • Phone: 920-264-5031
  • Fax:
Mailing address:
  • Phone: 920-264-5031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19627-130
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12615-123
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: