Provider Demographics
NPI:1992349617
Name:GUTIERREZ, ANGELIQUE C
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:C
Last Name:GUTIERREZ
Suffix:
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 1:1520 S ESPERANZA ST
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-4244
Mailing Address - Country:US
Mailing Address - Phone:575-418-7582
Mailing Address - Fax:
Practice Address - Street 1:123 DUPONT DR NW
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-4089
Practice Address - Country:US
Practice Address - Phone:803-648-0434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120131225X00000X
FLOT20143225X00000X
SC5586225X00000X
MO2018010808225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist