Basic Information
Provider Information | |||||||||
NPI: | 1336378116 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUTIERREZ | ||||||||
FirstName: | DIANE | ||||||||
MiddleName: | ELVIRA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GUTIERREZ | ||||||||
OtherFirstName: | DIANE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 160 E. VIRGINIA ST. | ||||||||
Address2: | STE. 280 | ||||||||
City: | SAN JOSE | ||||||||
State: | CA | ||||||||
PostalCode: | 95112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4082876200 | ||||||||
FaxNumber: | 4082876200 | ||||||||
Practice Location | |||||||||
Address1: | 160 E VIRGINIA ST | ||||||||
Address2: | STE, 280 | ||||||||
City: | SAN JOSE | ||||||||
State: | CA | ||||||||
PostalCode: | 951125857 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4082876200 | ||||||||
FaxNumber: | 4082876200 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/14/2009 | ||||||||
LastUpdateDate: | 07/29/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.