Provider Demographics
NPI:1427506591
Name:GUTIERREZ, MICHELLE A (LCSW)
Entity type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:A
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6417 RED YUCCA RD
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-6074
Mailing Address - Country:US
Mailing Address - Phone:832-721-6093
Mailing Address - Fax:
Practice Address - Street 1:697 LOUISIANA RD
Practice Address - Street 2:
Practice Address - City:DYESS AFB
Practice Address - State:TX
Practice Address - Zip Code:79607-1141
Practice Address - Country:US
Practice Address - Phone:325-696-8116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX534881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX53488OtherLICENSE