Provider Demographics
NPI:1982065587
Name:GUTIERREZ, MARILYN TATIANA
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:TATIANA
Last Name:GUTIERREZ
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 1:16530 VENTURA BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4551
Mailing Address - Country:US
Mailing Address - Phone:818-934-0626
Mailing Address - Fax:
Practice Address - Street 1:16530 VENTURA BLVD STE 400
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4551
Practice Address - Country:US
Practice Address - Phone:818-934-0626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2022-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMFT92172106H00000X
CALMFT117132106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist