=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255149035
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IAN ALEXANDER GUTIERREZ PHD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/24/2024
-----------------------------------------------------
Last Update Date | 12/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3717 DECATUR AVE
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 844-361-2273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9129 FLAMEPOOL WAY
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21045-2903
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-781-5395
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 06907
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------