Provider Demographics
NPI:1366723769
Name:GUTIERREZ, MELISSA (PT)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6301 UNIVERSITY COMMONS
Mailing Address - Street 2:SUITE 430
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1571
Mailing Address - Country:US
Mailing Address - Phone:574-968-2851
Mailing Address - Fax:574-968-2855
Practice Address - Street 1:6301 UNIVERSITY COMMONS
Practice Address - Street 2:SUITE 430
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1571
Practice Address - Country:US
Practice Address - Phone:574-968-2851
Practice Address - Fax:574-968-2855
Is Sole Proprietor?:No
Enumeration Date:2011-08-30
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01050166A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201056080Medicaid
OTH000Medicare UPIN
IN201056080Medicaid