Provider Demographics
NPI:1033289830
Name:GUTIERREZ, VANESSA M (OT)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:M
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1563
Mailing Address - Street 2:
Mailing Address - City:BERNALILLO
Mailing Address - State:NM
Mailing Address - Zip Code:87004-1563
Mailing Address - Country:US
Mailing Address - Phone:505-771-1434
Mailing Address - Fax:
Practice Address - Street 1:6519 4TH ST NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS DE ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-5812
Practice Address - Country:US
Practice Address - Phone:505-342-2500
Practice Address - Fax:505-342-2500
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1596174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM23974559Medicaid