Provider Demographics
NPI:1821410689
Name:GUTIERREZ, RAYMOND
Entity Type:Individual
Prefix:
First Name:RAYMOND
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 1:6724 ENSIGN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:91606-2025
Mailing Address - Country:US
Mailing Address - Phone:818-738-3011
Mailing Address - Fax:
Practice Address - Street 1:8140 SUNLAND BLVD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-3948
Practice Address - Country:US
Practice Address - Phone:818-582-8832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-14
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3908-I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)