Provider Demographics
NPI:1457038952
Name:GUTIERREZ, DEA LYNN (SUDRC)
Entity Type:Individual
Prefix:
First Name:DEA
Middle Name:LYNN
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:SUDRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1890 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LEMON GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:91945-4264
Mailing Address - Country:US
Mailing Address - Phone:619-603-3651
Mailing Address - Fax:
Practice Address - Street 1:1733 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5414
Practice Address - Country:US
Practice Address - Phone:619-263-0433
Practice Address - Fax:619-263-3992
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14906101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)