Provider Demographics
NPI:1619482940
Name:GUTIERREZ HERNANDEZ, MARILIS
Entity Type:Individual
Prefix:
First Name:MARILIS
Middle Name:
Last Name:GUTIERREZ HERNANDEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33013-4133
Mailing Address - Country:US
Mailing Address - Phone:305-742-2189
Mailing Address - Fax:305-742-2190
Practice Address - Street 1:747 E 19TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33013-4133
Practice Address - Country:US
Practice Address - Phone:305-742-2189
Practice Address - Fax:305-742-2190
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-18-71565106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician