Provider Demographics
NPI:1316315963
Name:GUTIERREZ, TAYLER PAIGE
Entity type:Individual
Prefix:
First Name:TAYLER
Middle Name:PAIGE
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TAYLER
Other - Middle Name:PAIGE
Other - Last Name:SWEET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2907 WILLIAMSON COUNTY PKWY
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-5256
Mailing Address - Country:US
Mailing Address - Phone:618-998-9894
Mailing Address - Fax:
Practice Address - Street 1:1112 OAK ST
Practice Address - Street 2:
Practice Address - City:CARMI
Practice Address - State:IL
Practice Address - Zip Code:62821-1344
Practice Address - Country:US
Practice Address - Phone:618-382-2927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-11
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.007185225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant