Provider Demographics
NPI:1568132835
Name:GUTIERREZ, ERIK (PTA)
Entity Type:Individual
Prefix:
First Name:ERIK
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 FOX RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE PLACID
Mailing Address - State:FL
Mailing Address - Zip Code:33852-8502
Mailing Address - Country:US
Mailing Address - Phone:863-633-9475
Mailing Address - Fax:
Practice Address - Street 1:400 CELEBRATION PL STE C200
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-4970
Practice Address - Country:US
Practice Address - Phone:863-633-9475
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA30954225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Multi-Specialty