Provider Demographics
NPI:1033941778
Name:GUTIERREZ, ADAM A (RBT)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:A
Last Name:GUTIERREZ
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:OK
Mailing Address - Zip Code:73570-9602
Mailing Address - Country:US
Mailing Address - Phone:580-418-8246
Mailing Address - Fax:
Practice Address - Street 1:401 S COLTRANE RD STE 206
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6720
Practice Address - Country:US
Practice Address - Phone:580-318-9415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKBCBA1174861106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty