Provider Demographics
NPI:1154843134
Name:GUTIERREZ, MELISSA NICOLE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:NICOLE
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 1:1837 CHAUCER DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-3502
Mailing Address - Country:US
Mailing Address - Phone:408-644-7552
Mailing Address - Fax:
Practice Address - Street 1:1887 MONTEREY HWY STE 205
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112
Practice Address - Country:US
Practice Address - Phone:408-971-9822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-12
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
09341128OtherKAISER