MEDICARE: TERESA J. GUTIERREZ LISW

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0005295036	OTHER	OH	AETNA PIN
2	000000168998	OTHER	OH	ANTHEM PROV. ID
3	341891557-001	OTHER	OH	MED MUT OH PROV. NO.
4	V34189155767813	OTHER	OH	HEALTHPARTNERS VENDOR NO.

General Provider Information

NPI Number	:	1508869504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA J. GUTIERREZ LISW

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	:	440-461-5033

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	:	440-461-5033

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	10/17/2007

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