Provider Demographics
NPI:1114415015
Name:GUTIERREZ, CARLY JEAN
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JEAN
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 1:106 VINEYARD AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:NY
Mailing Address - Zip Code:12528-1422
Mailing Address - Country:US
Mailing Address - Phone:845-691-9191
Mailing Address - Fax:
Practice Address - Street 1:106 VINEYARD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:NY
Practice Address - Zip Code:12528-1422
Practice Address - Country:US
Practice Address - Phone:845-691-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-25
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010069101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor