Provider Demographics
NPI:1659020097
Name:BARRERA GUTIERREZ, MARIA THERESA (SAC IT)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:THERESA
Last Name:BARRERA GUTIERREZ
Suffix:
Gender:F
Credentials:SAC IT
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 1085
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-1085
Mailing Address - Country:US
Mailing Address - Phone:920-264-5031
Mailing Address - Fax:
Practice Address - Street 1:621 E WALNUT ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-4001
Practice Address - Country:US
Practice Address - Phone:920-264-5031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI19627-130101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)