Provider Demographics
NPI:1891201034
Name:GUTIERREZ, MARJORIE ANN (HCP)
Entity Type:Individual
Prefix:
First Name:MARJORIE
Middle Name:ANN
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:HCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 N MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1119
Mailing Address - Country:US
Mailing Address - Phone:574-941-2220
Mailing Address - Fax:574-941-2227
Practice Address - Street 1:1407 N MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1119
Practice Address - Country:US
Practice Address - Phone:574-941-2220
Practice Address - Fax:574-941-2227
Is Sole Proprietor?:No
Enumeration Date:2017-12-26
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN17001319A237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN17001319AOtherINDIANA STATE LICENSE