Provider Demographics
NPI:1932713914
Name:PORTO GUTIERREZ, WALTER IVAN (MSW, LCSW)
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:IVAN
Last Name:PORTO GUTIERREZ
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18865 STATE ROAD 54 STE 233
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-8201
Mailing Address - Country:US
Mailing Address - Phone:954-890-2191
Mailing Address - Fax:
Practice Address - Street 1:18865 STATE ROAD 54 STE 233
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8201
Practice Address - Country:US
Practice Address - Phone:954-890-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-07
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW214761041C0700X
NY0980021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical