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NPI Code Detail

MEDICARE: MIRIAM P OWENS GUTIERRE LCPC

MEDICARE: MIRIAM P OWENS GUTIERRE LCPC
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
1101YA0400XAddiction (Substance Use Disorder) CounselorIL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
13636144473OTHERILEIN

General Provider Information

NPI Number : 1871618801
Entity Type Code : Individual
Provider Name (Legal Business Name) : MIRIAM P OWENS GUTIERRE LCPC
Provider Business Mailing Address
First Line : 422 TAG WAY
Second Line :
City : CRYSTAL LAKE
State : IL
Zip : 60014-6288
Country : US
Telephone Number : 815-444-6400
Fax Number : 815-444-6816
Provider Business Practice Location Address
First Line : 422 TAG WAY
Second Line :
City : CRYSTAL LAKE
State : IL
Zip : 60014-6288
Country : US
Telephone Number : 815-444-6400
Fax Number : 815-444-6816
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/20/2007
Last Update Date : 07/08/2007

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