Provider Demographics
NPI:1205579174
Name:GUTIERREZ LOPEZ, ANA I
Entity type:Individual
Prefix:
First Name:ANA
Middle Name:I
Last Name:GUTIERREZ LOPEZ
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 1:2707 FREEPORT RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-7710
Mailing Address - Country:US
Mailing Address - Phone:561-475-8501
Mailing Address - Fax:
Practice Address - Street 1:2707 FREEPORT RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33406-7710
Practice Address - Country:US
Practice Address - Phone:561-475-8501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-22-210466106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician