Provider Demographics
NPI:1013480243
Name:GUTIERREZ, BRIAN (BCBA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 N GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07067-2207
Mailing Address - Country:US
Mailing Address - Phone:732-754-1764
Mailing Address - Fax:
Practice Address - Street 1:35 N GRANT AVE
Practice Address - Street 2:
Practice Address - City:COLONIA
Practice Address - State:NJ
Practice Address - Zip Code:07067-2207
Practice Address - Country:US
Practice Address - Phone:732-754-1764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1-18-31733103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty