Provider Demographics
NPI:1417788480
Name:GUTIERREZ, AZUCENA R
Entity type:Individual
Prefix:
First Name:AZUCENA
Middle Name:R
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 1:4596 SW 174TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-5618
Mailing Address - Country:US
Mailing Address - Phone:754-281-3662
Mailing Address - Fax:
Practice Address - Street 1:12595 SW 137TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4218
Practice Address - Country:US
Practice Address - Phone:305-465-9379
Practice Address - Fax:305-203-4672
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH23989101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health