Provider Demographics
NPI:1205318847
Name:GUTIERREZ, EDGAR
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:GUTIERREZ
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:PO BOX 4672
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-0672
Mailing Address - Country:US
Mailing Address - Phone:509-456-5465
Mailing Address - Fax:509-456-5710
Practice Address - Street 1:518 S BROWNE ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2315
Practice Address - Country:US
Practice Address - Phone:509-456-5465
Practice Address - Fax:509-456-5710
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60811717101YA0400X
WA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor