Provider Demographics
NPI:1174846463
Name:GUTIERREZ, EDWARD RICHARD
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:RICHARD
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11490 AMBERRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-3705
Mailing Address - Country:US
Mailing Address - Phone:805-765-9050
Mailing Address - Fax:805-653-0567
Practice Address - Street 1:4760 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230-4820
Practice Address - Country:US
Practice Address - Phone:310-390-6612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-01
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health