Provider Demographics
NPI:1336340546
Name:GUTKOWSKI, PERRYN
Entity Type:Individual
Prefix:
First Name:PERRYN
Middle Name:
Last Name:GUTKOWSKI
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 1:1762 SEA PINE CIR
Mailing Address - Street 2:
Mailing Address - City:SEVERN
Mailing Address - State:MD
Mailing Address - Zip Code:21144-1815
Mailing Address - Country:US
Mailing Address - Phone:410-551-2455
Mailing Address - Fax:
Practice Address - Street 1:1202 ANNAPOLIS RD
Practice Address - Street 2:SUITE F
Practice Address - City:ODENTON
Practice Address - State:MD
Practice Address - Zip Code:21113-1387
Practice Address - Country:US
Practice Address - Phone:410-672-2862
Practice Address - Fax:410-672-2869
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY72072530101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY72072530Medicaid