Provider Demographics
NPI:1689052292
Name:GUTIERREZ, NICOLE MARIE (MA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17155 NEWHOPE ST STE L
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4233
Mailing Address - Country:US
Mailing Address - Phone:714-494-9136
Mailing Address - Fax:
Practice Address - Street 1:17821 17TH ST STE 260
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2161
Practice Address - Country:US
Practice Address - Phone:714-494-9136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93806106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist