MEDICARE: SILVIA GUADALUPE GUTIERREZ PH.D.

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist	PSY18553	CA
2	103TC2200X	Clinical Child & Adolescent Psychologist

General Provider Information

NPI Number	:	1164557559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SILVIA GUADALUPE GUTIERREZ PH.D.

Provider Business Mailing Address
First Line	:	3561 CLARINGTON AVE APT 105
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-4968
Country	:	US
Telephone Number	:	310-287-1408
Fax Number	:

Provider Business Practice Location Address
First Line	:	3250 WILSHIRE BLVD
Second Line	:	5TH FLOOR
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-1577
Country	:	US
Telephone Number	:	323-361-8322
Fax Number	:

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

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	07/05/2016

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