Provider Demographics
NPI:1619909207
Name:GUTZ, STEPHANIE A (LISW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:A
Last Name:GUTZ
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:EL PRADO
Mailing Address - State:NM
Mailing Address - Zip Code:87529-1077
Mailing Address - Country:US
Mailing Address - Phone:575-779-3391
Mailing Address - Fax:
Practice Address - Street 1:1219 GUSDORF RD.
Practice Address - Street 2:SUITE E
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6499
Practice Address - Country:US
Practice Address - Phone:575-779-3391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMI-066021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
610880Medicare ID - Type Unspecified