Provider Demographics
NPI:1215622089
Name:GUTIERREZ, ANTHONY ROBERT
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:ROBERT
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 4TH AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2564
Mailing Address - Country:US
Mailing Address - Phone:619-781-6312
Mailing Address - Fax:
Practice Address - Street 1:450 FLETCHER PARKWAY
Practice Address - Street 2:SUITE 226
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020
Practice Address - Country:US
Practice Address - Phone:619-781-6312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-07
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X, 251B00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No251B00000XAgenciesCase Management