Provider Demographics
NPI:1275672644
Name:GUTIERREZ, JUAN MANUEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUAN MANUEL
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 STATE ST
Mailing Address - Street 2:SUITE 26
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93101-3239
Mailing Address - Country:US
Mailing Address - Phone:805-965-1979
Mailing Address - Fax:
Practice Address - Street 1:827 STATE ST
Practice Address - Street 2:SUITE 26
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93101-3239
Practice Address - Country:US
Practice Address - Phone:805-965-1979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15192103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP15192BMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER