Provider Demographics
NPI:1427771146
Name:GUTIERREZ, DEEANNA
Entity type:Individual
Prefix:
First Name:DEEANNA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEE
Other - Middle Name:
Other - Last Name:ANNA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2919 BREEZEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5501
Mailing Address - Country:US
Mailing Address - Phone:910-484-1711
Mailing Address - Fax:
Practice Address - Street 1:102 SUPERIOR DR
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-3190
Practice Address - Country:US
Practice Address - Phone:910-484-1711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCABAT-13029106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician