Basic Information
| Provider Information | |||||||||
| NPI: | 1073730362 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GUTIERRES | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3501 MOON ST NE | ||||||||
| Address2: | MADISON MS | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871114619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052994735 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3501 MOON ST NE | ||||||||
| Address2: | MADISON MS | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871114619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052994735 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 235Z00000X | C 3844 | NM | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 88322068 | 05 | NM | MEDICAID |