Basic Information
| Provider Information | |||||||||
| NPI: | 1689974917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUTIERREZ | ||||||||
| FirstName: | RICK | ||||||||
| MiddleName: | DANIEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | BCBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GUTIERREZ | ||||||||
| OtherFirstName: | RICCARDO | ||||||||
| OtherMiddleName: | DANIEL | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | BCBA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7673 WIMBLETON CT | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917306695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094842848 | ||||||||
| FaxNumber: | 9094847257 | ||||||||
| Practice Location | |||||||||
| Address1: | 7673 WIMBLETON CT | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917306695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094842848 | ||||||||
| FaxNumber: | 9094847257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2010 | ||||||||
| LastUpdateDate: | 11/03/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-05-2251 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.