=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326441312
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN JOSE GUTIERREZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2014
-----------------------------------------------------
Last Update Date | 07/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11741 TELEGRAPH RD
-----------------------------------------------------
City | SANTA FE SPRINGS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90670-3681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-588-0255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3747 E 54TH ST
-----------------------------------------------------
City | MAYWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90270-2121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-400-9164
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 63064
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | ASW97254
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 225400000X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | ASW97254
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------