Provider Demographics
NPI:1073947966
Name:IGLESIAS, CONNIE GUTIERREZ (LCSW)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:GUTIERREZ
Last Name:IGLESIAS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 N BROADWAY FL 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-2803
Mailing Address - Country:US
Mailing Address - Phone:213-325-5567
Mailing Address - Fax:
Practice Address - Street 1:3303 N BROADWAY FL 4
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90031-2803
Practice Address - Country:US
Practice Address - Phone:213-325-5567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-27
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1009811041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program