Provider Demographics
NPI:1467006692
Name:GUTIERREZ, ANGELICA JASMINE
Entity Type:Individual
Prefix:
First Name:ANGELICA
Middle Name:JASMINE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10936 DALE AVE
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-2724
Mailing Address - Country:US
Mailing Address - Phone:714-952-4032
Mailing Address - Fax:
Practice Address - Street 1:10936 DALE AVE
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-2724
Practice Address - Country:US
Practice Address - Phone:714-952-4032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1239661216101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)