Provider Demographics
NPI:1770503948
Name:GUTMAKER, SUSAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:GUTMAKER
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 1:3393 IRIS AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-5205
Mailing Address - Country:US
Mailing Address - Phone:303-426-3630
Mailing Address - Fax:
Practice Address - Street 1:3393 IRIS AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-5205
Practice Address - Country:US
Practice Address - Phone:303-426-3630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO01389103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO79826598Medicaid
CO79826598Medicaid