1366723769 NPI number — MELISSA GUTIERREZ PT

Table of content: MELISSA GUTIERREZ PT (NPI 1366723769)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366723769 NPI number — MELISSA GUTIERREZ PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GUTIERREZ
Provider First Name:
MELISSA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366723769
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/06/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6301 UNIVERSITY COMMONS
Provider Second Line Business Mailing Address:
SUITE 430
Provider Business Mailing Address City Name:
SOUTH BEND
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46635-1571
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
574-968-2851
Provider Business Mailing Address Fax Number:
574-968-2855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6301 UNIVERSITY COMMONS
Provider Second Line Business Practice Location Address:
SUITE 430
Provider Business Practice Location Address City Name:
SOUTH BEND
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46635-1571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
574-968-2851
Provider Business Practice Location Address Fax Number:
574-968-2855
Provider Enumeration Date:
08/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  01050166A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 201056080 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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