Provider Demographics
NPI:1366047029
Name:GUTIERREZ, MELLISSA R
Entity type:Individual
Prefix:
First Name:MELLISSA
Middle Name:R
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25180 5TH ST APT 180
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-5162
Mailing Address - Country:US
Mailing Address - Phone:909-835-8919
Mailing Address - Fax:
Practice Address - Street 1:2275 E COOLEY DR
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-6324
Practice Address - Country:US
Practice Address - Phone:909-370-1777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)