Provider Demographics
NPI:1104396357
Name:GUTIERREZ, NATALYA T
Entity Type:Individual
Prefix:
First Name:NATALYA
Middle Name:T
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 VILLAGE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-1963
Mailing Address - Country:US
Mailing Address - Phone:954-296-1788
Mailing Address - Fax:
Practice Address - Street 1:4620 N STATE ROAD 7 STE 300
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-5867
Practice Address - Country:US
Practice Address - Phone:561-335-5681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-22-61883103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBTOtherREGISTERED BEHAVIOR TECHNICIAN