MEDICARE: TERESA J GUTIERREZ, LISW, INC.

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	1041C0700X	Clinical Social Worker	I4202	OH

General Provider Information

NPI Number	:	1104015072
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TERESA J GUTIERREZ, LISW, INC.

Provider Business Mailing Address
First Line	:	6009 LANDERHAVEN DR
Second Line	:	STE F
City	:	MAYFIELD HTS
State	:	OH
Zip	:	44124-4192
Country	:	US
Telephone Number	:	440-646-0671
Fax Number	:	440-641-5033

Provider Business Practice Location Address
First Line	:	6009 LANDERHAVEN DR
Second Line	:	STE F
City	:	MAYFIELD HTS
State	:	OH
Zip	:	44124-4192
Country	:	US
Telephone Number	:	440-646-0671
Fax Number	:	440-641-5033

Authorized Official
Title or Position	:	PRESIDENT
Name	:	TERESA J GUTIERREZ
Credential	:	LISW
Telephone Number	:	440-646-0671

Provider Enumeration Date	:	10/17/2007
Last Update Date	:	10/17/2007

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