Provider Demographics
NPI:1831152131
Name:GUTIERREZ, TERESA M (OT CHT)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:M
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:OT CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 RACETRACK RD NE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-2561
Mailing Address - Country:US
Mailing Address - Phone:850-863-4747
Mailing Address - Fax:850-863-4658
Practice Address - Street 1:405 RACETRACK RD NE
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-2561
Practice Address - Country:US
Practice Address - Phone:850-863-4747
Practice Address - Fax:850-863-4658
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT364225X00000X
GAOT002560225X00000X
FLCHT9105000452225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL890873700Medicaid
GA00833621BMedicaid