Provider Demographics
NPI:1578286969
Name:GUTIERREZ, GREIVIS JOSE SR
Entity Type:Individual
Prefix:
First Name:GREIVIS
Middle Name:JOSE
Last Name:GUTIERREZ
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 CREEKMONT LN UNIT 201
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-6295
Mailing Address - Country:US
Mailing Address - Phone:407-954-2438
Mailing Address - Fax:
Practice Address - Street 1:2125 CREEKMONT LN UNIT 201
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-6295
Practice Address - Country:US
Practice Address - Phone:407-954-2438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL22-234498106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician