Provider Demographics
NPI:1811421829
Name:GUTIERREZ, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6601 MONTANA AVE STE G&H
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79925-2155
Mailing Address - Country:US
Mailing Address - Phone:915-838-7604
Mailing Address - Fax:915-772-4633
Practice Address - Street 1:6601 MONTANA AVE STE G&H
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79925-2155
Practice Address - Country:US
Practice Address - Phone:915-838-7604
Practice Address - Fax:915-772-4633
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX118356225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist