Provider Demographics
NPI:1336653906
Name:CREECY-GUTIERREZ, SHALADA CRISTAL (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:SHALADA
Middle Name:CRISTAL
Last Name:CREECY-GUTIERREZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 740018
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0018
Mailing Address - Country:US
Mailing Address - Phone:113-759-7550
Mailing Address - Fax:312-929-0373
Practice Address - Street 1:5555 ZUNI RD SE STE 11
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2935
Practice Address - Country:US
Practice Address - Phone:505-777-3002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-18
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-10293104100000X
NMC-118081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker