Provider Demographics
NPI:1073733903
Name:GUTIERREZ, MARY AMINTA (MFT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:AMINTA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 BERENDA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-4115
Mailing Address - Country:US
Mailing Address - Phone:650-588-5105
Mailing Address - Fax:
Practice Address - Street 1:1670 S AMPHLETT BLVD
Practice Address - Street 2:SUITE 115
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2510
Practice Address - Country:US
Practice Address - Phone:650-349-7969
Practice Address - Fax:650-349-1103
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC37575106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist