Provider Demographics
NPI:1346554896
Name:GUTIERREZ, GUSTAVO J (LCSW)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:J
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12308 S.W. 123 PASSAGE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-5471
Mailing Address - Country:US
Mailing Address - Phone:786-242-5140
Mailing Address - Fax:
Practice Address - Street 1:16201 SW 95TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33157-3459
Practice Address - Country:US
Practice Address - Phone:786-293-3077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW23531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical