Provider Demographics
NPI:1134801046
Name:ELLIOTT GUTIERREZ, JO (LMT, MLD-C)
Entity type:Individual
Prefix:
First Name:JO
Middle Name:
Last Name:ELLIOTT GUTIERREZ
Suffix:
Gender:F
Credentials:LMT, MLD-C
Other - Prefix:
Other - First Name:JOSEPHINE
Other - Middle Name:DELL
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:930 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-3234
Mailing Address - Country:US
Mailing Address - Phone:603-345-2749
Mailing Address - Fax:
Practice Address - Street 1:930 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3234
Practice Address - Country:US
Practice Address - Phone:603-345-2749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16722225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist