Provider Demographics
NPI:1104975465
Name:GUTIERREZ, IRIS V (LCSW)
Entity type:Individual
Prefix:MS
First Name:IRIS
Middle Name:V
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MEDICAL VILLAGE DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-5401
Mailing Address - Country:US
Mailing Address - Phone:859-341-5014
Mailing Address - Fax:859-341-5136
Practice Address - Street 1:1306 VERSAILLES RD STE 120
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-1795
Practice Address - Country:US
Practice Address - Phone:859-259-2635
Practice Address - Fax:859-254-7874
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5078171M00000X
KY37691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100274070Medicaid
KYK118470OtherMEDICARE ID