Provider Demographics
NPI:1740809896
Name:GUTIERREZ, FATIMA (PTA)
Entity type:Individual
Prefix:
First Name:FATIMA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1329 BARTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4419
Mailing Address - Country:US
Mailing Address - Phone:909-255-1694
Mailing Address - Fax:909-307-0273
Practice Address - Street 1:264 N HIGHLAND SPRINGS AVE STE 4
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3082
Practice Address - Country:US
Practice Address - Phone:951-769-7900
Practice Address - Fax:888-854-7592
Is Sole Proprietor?:No
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPTA50541225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant