Provider Demographics
NPI:1265024889
Name:GUTIERREZ-DIAZ, MARIE A (MSW)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:A
Last Name:GUTIERREZ-DIAZ
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:A
Other - Last Name:GUTIERREZ-DIAZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:81 STOREY AVE
Mailing Address - Street 2:
Mailing Address - City:BELEN
Mailing Address - State:NM
Mailing Address - Zip Code:87002-9203
Mailing Address - Country:US
Mailing Address - Phone:505-388-4925
Mailing Address - Fax:
Practice Address - Street 1:428 LOS LENTES RD SE # 3
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-6018
Practice Address - Country:US
Practice Address - Phone:505-865-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-04
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-11450104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker