Provider Demographics
NPI:1073866828
Name:GUTIERREZ, JOSHUA LEE (LAC)
Entity Type:Individual
Prefix:MR
First Name:JOSHUA
Middle Name:LEE
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 POPLAR RD
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-1016
Mailing Address - Country:US
Mailing Address - Phone:631-481-6478
Mailing Address - Fax:
Practice Address - Street 1:1700 GREAT NECK RD
Practice Address - Street 2:
Practice Address - City:COPIAGUE
Practice Address - State:NY
Practice Address - Zip Code:11726-2723
Practice Address - Country:US
Practice Address - Phone:631-481-6478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-17
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004878171100000X
NY020015225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist