Provider Demographics
NPI:1710425624
Name:GUTIERREZ, PAMELA ANN (LADAC)
Entity Type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:ANN
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:LADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 SILVER AVE SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-2748
Mailing Address - Country:US
Mailing Address - Phone:505-255-1804
Mailing Address - Fax:
Practice Address - Street 1:4300 SILVER AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-2748
Practice Address - Country:US
Practice Address - Phone:505-255-1804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0130101101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)