Provider Demographics
NPI:1689358715
Name:GUTIERREZ, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
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 1:11987 VENETIAN DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92557-6520
Mailing Address - Country:US
Mailing Address - Phone:951-400-2612
Mailing Address - Fax:
Practice Address - Street 1:1274 CENTER COURT DR STE 211
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3668
Practice Address - Country:US
Practice Address - Phone:626-339-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12365758103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst