Provider Demographics
NPI:1194532531
Name:GUTIERREZ, MARIALISA GUADALUPE
Entity type:Individual
Prefix:
First Name:MARIALISA
Middle Name:GUADALUPE
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 1:800 N PINE ST APT 4203
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-3289
Mailing Address - Country:US
Mailing Address - Phone:503-710-8096
Mailing Address - Fax:
Practice Address - Street 1:800 N PINE ST APT 4203
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-3289
Practice Address - Country:US
Practice Address - Phone:503-710-8096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician