Provider Demographics
NPI:1730467127
Name:GUTIERREZ, DORA VIVIANA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:DORA
Middle Name:VIVIANA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 BROADWAY
Mailing Address - Street 2:17TH FL.
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-4640
Mailing Address - Country:US
Mailing Address - Phone:212-851-8101
Mailing Address - Fax:212-537-0102
Practice Address - Street 1:1745 BROADWAY
Practice Address - Street 2:17TH FL.
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-4640
Practice Address - Country:US
Practice Address - Phone:212-851-8101
Practice Address - Fax:212-537-0102
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013844103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical