Provider Demographics
NPI:1164170932
Name:GUTIERREZ, DAMARIS (ITDS & RBT)
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:ITDS & RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-5010
Mailing Address - Country:US
Mailing Address - Phone:305-794-3390
Mailing Address - Fax:
Practice Address - Street 1:8491 NW 17TH ST STE 110
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1025
Practice Address - Country:US
Practice Address - Phone:305-456-5542
Practice Address - Fax:786-598-7590
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-89497106S00000X
252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL105159600Medicaid