Provider Demographics
NPI:1760467963
Name:GUTIERREZ, CHARLES E (PHD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 DATAPOINT DR STE301
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5904
Mailing Address - Country:US
Mailing Address - Phone:210-354-1186
Mailing Address - Fax:210-354-1187
Practice Address - Street 1:8401 DATAPOINT DR STE 301
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5904
Practice Address - Country:US
Practice Address - Phone:210-354-1186
Practice Address - Fax:210-354-1187
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31016103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX036343403Medicaid
TX7979798OtherCIGNA
TX87436AOtherBLUE CROSS BLUE SHIELD
TX00U84XOtherBLUE CROSS PROVIDER NUMBE