Provider Demographics
NPI:1124988688
Name:GUTIERREZ CID, MARIOLIS
Entity type:Individual
Prefix:
First Name:MARIOLIS
Middle Name:
Last Name:GUTIERREZ CID
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 1:157 W 12TH ST
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33010-3912
Mailing Address - Country:US
Mailing Address - Phone:786-286-5106
Mailing Address - Fax:
Practice Address - Street 1:157 W 12TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-3912
Practice Address - Country:US
Practice Address - Phone:786-286-5106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-17
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL25491314106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty