Basic Information
| Provider Information | |||||||||
| NPI: | 1750529228 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUTIERREZ | ||||||||
| FirstName: | IRENE | ||||||||
| MiddleName: | IVETTE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CAVAZOS | ||||||||
| OtherFirstName: | IRENE | ||||||||
| OtherMiddleName: | IVETTE | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4163 E EL MONTE WAY | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5593628074 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 611 E BELMONT AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937011502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592373420 | ||||||||
| FaxNumber: | 5594857244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2009 | ||||||||
| LastUpdateDate: | 01/21/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.