Provider Demographics
NPI:1013287572
Name:GUTIERREZ WANG, LISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:GUTIERREZ WANG
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GUTIERREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:1400 EMELINE AVENUE
Mailing Address - Street 2:BUILDING K
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060
Mailing Address - Country:US
Mailing Address - Phone:831-454-4948
Mailing Address - Fax:831-454-4916
Practice Address - Street 1:1400 EMELINE AVENUE
Practice Address - Street 2:BUILDING K
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060
Practice Address - Country:US
Practice Address - Phone:831-454-4948
Practice Address - Fax:831-454-4916
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2019-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23588103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist