Basic Information
| Provider Information | |||||||||
| NPI: | 1205593282 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUTIERREZ ACKERELY | ||||||||
| FirstName: | EVA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | TCADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 320 N EISENHOWER AVE | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504011521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414242391 | ||||||||
| FaxNumber: | 6414240783 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 N EISENHOWER AVE | ||||||||
| Address2: | |||||||||
| City: | MASON CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 504011521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6414242391 | ||||||||
| FaxNumber: | 6414240783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2021 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | T21112 | IA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1952443632 | 05 | IA | MEDICAID |