Provider Demographics
NPI:1598814840
Name:GUTIERREZ, STACY MARIE (AT,C)
Entity Type:Individual
Prefix:MISS
First Name:STACY
Middle Name:MARIE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:AT,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14349 LEROY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-2066
Mailing Address - Country:US
Mailing Address - Phone:313-657-3675
Mailing Address - Fax:
Practice Address - Street 1:14349 LEROY ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2066
Practice Address - Country:US
Practice Address - Phone:313-657-3675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer