Provider Demographics
NPI:1649095290
Name:GUTIERREZ, ANGEL GUILLERMO JR (MS ED, CAS, NCSP)
Entity type:Individual
Prefix:
First Name:ANGEL
Middle Name:GUILLERMO
Last Name:GUTIERREZ
Suffix:JR
Gender:M
Credentials:MS ED, CAS, NCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1477 S SCHODACK RD
Mailing Address - Street 2:
Mailing Address - City:CASTLETON ON HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9644
Mailing Address - Country:US
Mailing Address - Phone:518-477-7103
Mailing Address - Fax:
Practice Address - Street 1:1477 S SCHODACK RD
Practice Address - Street 2:
Practice Address - City:CASTLETON ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12033-9644
Practice Address - Country:US
Practice Address - Phone:518-477-7103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2877844103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool