Provider Demographics
NPI:1073834602
Name:GUTIERREZ, TESSA (LSCSW, LCAC)
Entity Type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:LSCSW, LCAC
Other - Prefix:
Other - First Name:TESSA
Other - Middle Name:
Other - Last Name:FALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:929 S WASHINGTON ST.
Mailing Address - Street 2:
Mailing Address - City:JUNCTION CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66441
Mailing Address - Country:US
Mailing Address - Phone:785-802-9024
Mailing Address - Fax:
Practice Address - Street 1:929 S WASHINGTON ST.
Practice Address - Street 2:
Practice Address - City:JUNCTION CITY
Practice Address - State:KS
Practice Address - Zip Code:66441
Practice Address - Country:US
Practice Address - Phone:785-802-9024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS524101YA0400X
KS42071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)