Provider Demographics
NPI:1467732248
Name:GUTIERREZ, SIMON B
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:B
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 1:3604 GALLEY RD
Mailing Address - Street 2:STE 200
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909
Mailing Address - Country:US
Mailing Address - Phone:719-550-4613
Mailing Address - Fax:
Practice Address - Street 1:3604 GALLEY RD
Practice Address - Street 2:STE 200
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909
Practice Address - Country:US
Practice Address - Phone:719-550-4613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6609225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist