Provider Demographics
NPI:1003532821
Name:GUTIERREZ, MARIAH ANGELICA
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:ANGELICA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:A
Other - Last Name:SANTILLANES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:72 JOURNEY RD
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-8037
Mailing Address - Country:US
Mailing Address - Phone:505-514-1530
Mailing Address - Fax:
Practice Address - Street 1:536 LOS LENTES RD SE
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-7052
Practice Address - Country:US
Practice Address - Phone:505-514-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst