Provider Demographics
NPI:1740558584
Name:GUTIERREZ, KENNER (MA)
Entity Type:Individual
Prefix:
First Name:KENNER
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13595 SW 134TH AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4580
Mailing Address - Country:US
Mailing Address - Phone:786-218-7690
Mailing Address - Fax:305-259-6778
Practice Address - Street 1:13595 SW 134TH AVE STE 207
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4580
Practice Address - Country:US
Practice Address - Phone:786-218-7690
Practice Address - Fax:305-259-6778
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 64023225700000X
FLPTA26844225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist