Provider Demographics
NPI:1700524881
Name:GUTIERREZ -ALI, GLADYS CRYSTAL
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:CRYSTAL
Last Name:GUTIERREZ -ALI
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 1:3023 N CAMINO LAGOS
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75054-6797
Mailing Address - Country:US
Mailing Address - Phone:817-880-1555
Mailing Address - Fax:
Practice Address - Street 1:1016 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-1745
Practice Address - Country:US
Practice Address - Phone:817-299-4330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX345072355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX465617571Medicaid