Provider Demographics
NPI:1457924912
Name:ROQUE GUTIERREZ, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:ROQUE GUTIERREZ
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 1:903 BERTHA FULSE ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:FL
Mailing Address - Zip Code:33834-5138
Mailing Address - Country:US
Mailing Address - Phone:863-578-9235
Mailing Address - Fax:
Practice Address - Street 1:171 WEBB DR STE 2
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-3963
Practice Address - Country:US
Practice Address - Phone:863-270-1339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician