Provider Demographics
NPI:1073124376
Name:GUTIERREZ, MARIA VICTORIA (LMT)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:VICTORIA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:
Other - Last Name:GUTIERREZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMT
Mailing Address - Street 1:4250 WARWICK WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-3856
Mailing Address - Country:US
Mailing Address - Phone:608-772-0121
Mailing Address - Fax:
Practice Address - Street 1:2702 MONROE ST STE 110
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-1896
Practice Address - Country:US
Practice Address - Phone:608-772-0121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI625-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist