Provider Demographics
NPI:1043531783
Name:GUTIERREZ, PRISCILLA MARIE (MS, LMHC)
Entity Type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:MARIE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1260 MERCANTIL AVE
Mailing Address - Street 2:
Mailing Address - City:ANTHONY
Mailing Address - State:NM
Mailing Address - Zip Code:88021-8443
Mailing Address - Country:US
Mailing Address - Phone:915-346-3253
Mailing Address - Fax:
Practice Address - Street 1:9741 CANDELARIA RD NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1401
Practice Address - Country:US
Practice Address - Phone:505-219-3620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCMH0200861101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty