MEDICARE: BRIAN GUTIERREZ BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	15BC00011700	NJ

General Provider Information

NPI Number	:	1013480243
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN GUTIERREZ BCBA

Provider Business Mailing Address
First Line	:	35 N GRANT AVE
Second Line	:
City	:	COLONIA
State	:	NJ
Zip	:	07067-2207
Country	:	US
Telephone Number	:	732-754-1764
Fax Number	:

Provider Business Practice Location Address
First Line	:	35 N GRANT AVE
Second Line	:
City	:	COLONIA
State	:	NJ
Zip	:	07067-2207
Country	:	US
Telephone Number	:	732-754-1764
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2019
Last Update Date	:	05/11/2026

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