Provider Demographics
NPI:1487238630
Name:GUTIERREZ MORENO, SEYLI MARIA I
Entity type:Individual
Prefix:MISS
First Name:SEYLI
Middle Name:MARIA
Last Name:GUTIERREZ MORENO
Suffix:I
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 1:6413 N HUMBERT AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-4842
Mailing Address - Country:US
Mailing Address - Phone:813-820-7543
Mailing Address - Fax:
Practice Address - Street 1:3309 W WATERS AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-2766
Practice Address - Country:US
Practice Address - Phone:813-898-0014
Practice Address - Fax:813-898-0015
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty