Provider Demographics
NPI:1699249557
Name:GUTIERREZ, ANGELA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:
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 1:2428 SEA HORSE ST
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-6509
Mailing Address - Country:US
Mailing Address - Phone:219-841-2316
Mailing Address - Fax:
Practice Address - Street 1:2428 SEA HORSE ST
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-6509
Practice Address - Country:US
Practice Address - Phone:219-841-2316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008103A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical