Provider Demographics
NPI:1093484727
Name:GUTIERREZ, AMANDA CLARISSA (BA PSYCH)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:CLARISSA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:BA PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1209 N LYMAN AVE APT 106
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-1862
Mailing Address - Country:US
Mailing Address - Phone:233-218-3095
Mailing Address - Fax:
Practice Address - Street 1:5190 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-6510
Practice Address - Country:US
Practice Address - Phone:818-996-1051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)