Provider Demographics
NPI:1538506944
Name:GUTIERREZ, MARY DEBRA (MPT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:DEBRA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 SIERRA COLLEGE DR
Mailing Address - Street 2:165
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5082
Mailing Address - Country:US
Mailing Address - Phone:530-274-2320
Mailing Address - Fax:530-274-1568
Practice Address - Street 1:300 SIERRA COLLEGE DR
Practice Address - Street 2:165
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5082
Practice Address - Country:US
Practice Address - Phone:530-274-2320
Practice Address - Fax:530-274-1568
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 18279225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist