Provider Demographics
NPI:1508869504
Name:GUTIERREZ, TERESA J (LISW)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:J
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6009 LANDERHAVEN DR
Mailing Address - Street 2:STE F
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-4192
Mailing Address - Country:US
Mailing Address - Phone:440-646-0671
Mailing Address - Fax:440-461-5033
Practice Address - Street 1:6009 LANDERHAVEN DR
Practice Address - Street 2:STE F
Practice Address - City:MAYFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44124-4192
Practice Address - Country:US
Practice Address - Phone:440-646-0671
Practice Address - Fax:440-461-5033
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI42021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0005295036OtherAETNA PIN
OH000000168998OtherANTHEM PROV. ID
OH341891557-001OtherMED MUT OH PROV. NO.
OHV34189155767813OtherHEALTHPARTNERS VENDOR NO.
OHV34189155767813OtherHEALTHPARTNERS VENDOR NO.