Provider Demographics
NPI:1386269025
Name:GUTOW, MINDY (PHD)
Entity type:Individual
Prefix:DR
First Name:MINDY
Middle Name:
Last Name:GUTOW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7013 RIO GRANDE BLVD NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-6423
Mailing Address - Country:US
Mailing Address - Phone:505-398-3624
Mailing Address - Fax:
Practice Address - Street 1:7013 RIO GRANDE BLVD NW
Practice Address - Street 2:
Practice Address - City:LOS RANCHOS
Practice Address - State:NM
Practice Address - Zip Code:87107-6423
Practice Address - Country:US
Practice Address - Phone:505-398-3624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0936103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical