Provider Demographics
NPI:1710651302
Name:GUTERRES, ANTONIO TAIGA
Entity type:Individual
Prefix:
First Name:ANTONIO TAIGA
Middle Name:
Last Name:GUTERRES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ANTONIO
Other - Middle Name:TAIGA
Other - Last Name:GUTERRES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16 SEVEN OAKS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01862-1124
Mailing Address - Country:US
Mailing Address - Phone:626-354-2530
Mailing Address - Fax:
Practice Address - Street 1:233 HARVARD ST STE 339
Practice Address - Street 2:
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-5032
Practice Address - Country:US
Practice Address - Phone:617-798-0923
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALCSW2289791041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker