Basic Information
| Provider Information | |||||||||
| NPI: | 1912287970 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUTIERREZ | ||||||||
| FirstName: | EVANGELINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | LPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2219 MOUNTAIN AVE | ||||||||
| Address2: | |||||||||
| City: | DUARTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268273833 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 66 HURLBUT ST | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911054025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264414221 | ||||||||
| FaxNumber: | 6267991246 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2011 | ||||||||
| LastUpdateDate: | 08/23/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | PT 36097 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.