Provider Demographics
NPI:1326441312
Name:GUTIERREZ, JUAN JOSE
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:JOSE
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 1:3747 E 54TH ST
Mailing Address - Street 2:
Mailing Address - City:MAYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90270-2121
Mailing Address - Country:US
Mailing Address - Phone:213-400-9164
Mailing Address - Fax:
Practice Address - Street 1:11741 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3681
Practice Address - Country:US
Practice Address - Phone:323-588-0255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63064101YM0800X
CAASW97254101YM0800X, 104100000X
CA225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner