Provider Demographics
NPI:1902395197
Name:GUTIERREZ, LISANDRA
Entity Type:Individual
Prefix:
First Name:LISANDRA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 W 79TH ST APT 113A
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33014-3553
Mailing Address - Country:US
Mailing Address - Phone:786-325-9918
Mailing Address - Fax:
Practice Address - Street 1:3350 SW 148TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-3237
Practice Address - Country:US
Practice Address - Phone:954-734-2737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician