Provider Demographics
NPI:1255370276
Name:GUTIN, STEVEN VYACHESLAV (PT)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:VYACHESLAV
Last Name:GUTIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 SHEEPSHEAD BAY ROAD
Mailing Address - Street 2:APT 5A
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235
Mailing Address - Country:US
Mailing Address - Phone:347-922-4349
Mailing Address - Fax:
Practice Address - Street 1:726 AVE Z
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11223
Practice Address - Country:US
Practice Address - Phone:718-872-7373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021863225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQC5381Medicare ID - Type Unspecified