Provider Demographics
NPI:1962721647
Name:GUTIERREZ, MAYRA VERONICA (AA)
Entity type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:VERONICA
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:MAYRA
Other - Middle Name:VERONICA
Other - Last Name:DOMINGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4212 DELAND AVE
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-1705
Mailing Address - Country:US
Mailing Address - Phone:562-639-7476
Mailing Address - Fax:
Practice Address - Street 1:4212 DELAND AVE
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-1705
Practice Address - Country:US
Practice Address - Phone:562-639-7476
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-20
Last Update Date:2016-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA324224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant