Provider Demographics
NPI:1710141650
Name:GUTIERREZ, KARISSA MARIE (OTR/L)
Entity Type:Individual
Prefix:MISS
First Name:KARISSA
Middle Name:MARIE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:OTR/L
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 450
Mailing Address - Street 2:
Mailing Address - City:SCOTT DEPOT
Mailing Address - State:WV
Mailing Address - Zip Code:25560-0450
Mailing Address - Country:US
Mailing Address - Phone:304-760-6300
Mailing Address - Fax:304-201-5123
Practice Address - Street 1:948 W PIKE ST
Practice Address - Street 2:SUITE B
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-2529
Practice Address - Country:US
Practice Address - Phone:304-326-2070
Practice Address - Fax:304-326-2071
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV 1437225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist