Provider Demographics
NPI:1083292635
Name:GUTIERREZ, MARK ANTHONY (LPC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ANTHONY
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 ISLA BAHIA WAY
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-3133
Mailing Address - Country:US
Mailing Address - Phone:915-694-3638
Mailing Address - Fax:
Practice Address - Street 1:3205 ISLA BAHIA WAY
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-3133
Practice Address - Country:US
Practice Address - Phone:915-694-3638
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX75999101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor