Provider Demographics
NPI:1861576522
Name:GUTIERREZ, MICHAEL E
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:E
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 TERRAINNE DR
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780
Mailing Address - Country:US
Mailing Address - Phone:508-824-0699
Mailing Address - Fax:
Practice Address - Street 1:SOUTH BAY MENTAL HEALTH CENTER
Practice Address - Street 2:37 BELMONT ST
Practice Address - City:BRACKTON
Practice Address - State:MA
Practice Address - Zip Code:08301
Practice Address - Country:US
Practice Address - Phone:508-580-4691
Practice Address - Fax:508-588-5751
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11130104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP22911Medicare ID - Type Unspecified