Provider Demographics
NPI:1528420163
Name:GUTIERREZ, MAYRA RIVAS (LCSW)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:RIVAS
Last Name:GUTIERREZ
Suffix:
Gender:F
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:PO BOX 1203
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-1203
Mailing Address - Country:US
Mailing Address - Phone:323-432-4898
Mailing Address - Fax:
Practice Address - Street 1:2425 W WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-3040
Practice Address - Country:US
Practice Address - Phone:323-432-4898
Practice Address - Fax:323-238-1941
Is Sole Proprietor?:No
Enumeration Date:2016-03-23
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA844621041C0700X
CA1141821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program