MEDICARE: SAMANTHA ALIX GUTIERREZ

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1396591129
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA ALIX GUTIERREZ

Provider Business Mailing Address
First Line	:	49 EL CERRO LOOP
Second Line	:
City	:	LOS LUNAS
State	:	NM
Zip	:	87031-7261
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	49 EL CERRO LOOP
Second Line	:
City	:	LOS LUNAS
State	:	NM
Zip	:	87031-7261
Country	:	US
Telephone Number	:	505-261-4779
Fax Number	:

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

Provider Enumeration Date	:	04/24/2024
Last Update Date	:	04/24/2024

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