Provider Demographics
NPI:1740339977
Name:GUTBROD, VICTORIA ANN (LPCC)
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:ANN
Last Name:GUTBROD
Suffix:
Gender:F
Credentials:LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2680 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-4215
Mailing Address - Country:US
Mailing Address - Phone:234-867-5001
Mailing Address - Fax:
Practice Address - Street 1:2680 W MARKET ST
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-4215
Practice Address - Country:US
Practice Address - Phone:234-867-5001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE0004392101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2651189Medicaid
OH000000498082OtherANTHEM
OH831899000OtherMAGELLAN