Provider Demographics
NPI:1275170193
Name:GUTIERREZ, MELANI (BS)
Entity Type:Individual
Prefix:MRS
First Name:MELANI
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:BS
Other - Prefix:MISS
Other - First Name:MELANI
Other - Middle Name:
Other - Last Name:MONTGOMERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1313 N YOUNG ST STE E
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7662
Mailing Address - Country:US
Mailing Address - Phone:509-760-4769
Mailing Address - Fax:
Practice Address - Street 1:7401 W GRANDRIDGE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7831
Practice Address - Country:US
Practice Address - Phone:206-388-0544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
WACG61314557101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician