Provider Demographics
NPI:1659992782
Name:GUTIERREZ, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 MAITLAND CENTER PKWY STE 240
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2199 H DELA ROSA SR ST
Practice Address - Street 2:
Practice Address - City:SOLEDAD
Practice Address - State:CA
Practice Address - Zip Code:93960-3381
Practice Address - Country:US
Practice Address - Phone:831-223-4949
Practice Address - Fax:407-965-4480
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0-21-12087106E00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst