Provider Demographics
NPI:1831501147
Name:GUTIERREZ, MARI LYNN SCARLETT (LCSW)
Entity Type:Individual
Prefix:
First Name:MARI LYNN
Middle Name:SCARLETT
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARI LYNN
Other - Middle Name:
Other - Last Name:REIKOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1096 MECHEM DR STE 213
Mailing Address - Street 2:
Mailing Address - City:RUIDOSO
Mailing Address - State:NM
Mailing Address - Zip Code:88345-7068
Mailing Address - Country:US
Mailing Address - Phone:752-233-8184
Mailing Address - Fax:
Practice Address - Street 1:1096 MECHEM DR STE 213
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345-7068
Practice Address - Country:US
Practice Address - Phone:575-223-8184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-098381041C0700X
171M00000X
NMC-108491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM95636757Medicaid