Provider Demographics
NPI:1952577488
Name:GUTIERREZ, PATRICIA ROSE (CSAC, ICS, LPC)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ROSE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:CSAC, ICS, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 RANDALL ST
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-3528
Mailing Address - Country:US
Mailing Address - Phone:262-510-8490
Mailing Address - Fax:
Practice Address - Street 1:147 RANDALL ST
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-3528
Practice Address - Country:US
Practice Address - Phone:262-510-8490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7295-125101YM0800X
WI11046-132101YA0400X
WI11046101YA0400X
101YP2500X
7295-125101YP2500X
WI101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39384900Medicaid
WI1952577488Medicaid