Provider Demographics
NPI:1457169401
Name:GUTIERRES, DAMIAN N
Entity type:Individual
Prefix:
First Name:DAMIAN
Middle Name:N
Last Name:GUTIERRES
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:DANNI
Other - Middle Name:N
Other - Last Name:GUTIERRES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6901 LEEDOM RD
Mailing Address - Street 2:
Mailing Address - City:HUGHSON
Mailing Address - State:CA
Mailing Address - Zip Code:95326-9232
Mailing Address - Country:US
Mailing Address - Phone:209-493-8707
Mailing Address - Fax:
Practice Address - Street 1:3224 MCHENRY AVE
Practice Address - Street 2:SUITE E
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-493-8707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA236Medicaid
CA568946544OtherBCBS
CA5874OtherHEALTH PARTNERS