Provider Demographics
NPI:1619587045
Name:GUTIERREZ, LILIA
Entity Type:Individual
Prefix:
First Name:LILIA
Middle Name:
Last Name:GUTIERREZ
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 1:2139 S CLOVERDALE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-1211
Mailing Address - Country:US
Mailing Address - Phone:323-422-0853
Mailing Address - Fax:
Practice Address - Street 1:2139 S CLOVERDALE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-1211
Practice Address - Country:US
Practice Address - Phone:323-422-0853
Practice Address - Fax:323-372-3970
Is Sole Proprietor?:No
Enumeration Date:2020-07-31
Last Update Date:2022-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator