Provider Demographics
NPI:1013660240
Name:GUTSTADT, MATTHEW
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:
Last Name:GUTSTADT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 NE 24TH WAY
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-3569
Mailing Address - Country:US
Mailing Address - Phone:954-557-0319
Mailing Address - Fax:
Practice Address - Street 1:750 NE 24TH WAY
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3569
Practice Address - Country:US
Practice Address - Phone:954-557-0319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-28
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL000787000320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities