=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619483708
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANIA GUTIERREZ-LARIOS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/27/2017
-----------------------------------------------------
Last Update Date | 12/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 SNEATH LN STE 105
-----------------------------------------------------
City | SAN BRUNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94066-2415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-223-7123
-----------------------------------------------------
Fax | 619-374-7134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 33568
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92163-3568
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 855-223-7123
-----------------------------------------------------
Fax | 619-374-7134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 1-17-28253
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------