Provider Demographics
NPI:1477245785
Name:GUTIERREZ, LISA (LPC-IT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:LPC-IT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1820 CENTER AVE STE 170
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2878
Mailing Address - Country:US
Mailing Address - Phone:608-755-1475
Mailing Address - Fax:608-755-1733
Practice Address - Street 1:1820 CENTER AVE STE 170
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2878
Practice Address - Country:US
Practice Address - Phone:608-755-1475
Practice Address - Fax:608-755-1733
Is Sole Proprietor?:No
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7315-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional