Provider Demographics
NPI:1255149035
Name:GUTIERREZ, IAN ALEXANDER (PHD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:ALEXANDER
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9129 FLAMEPOOL WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-2903
Mailing Address - Country:US
Mailing Address - Phone:440-781-5395
Mailing Address - Fax:
Practice Address - Street 1:3717 DECATUR AVE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2148
Practice Address - Country:US
Practice Address - Phone:844-361-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-24
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06907103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist