Provider Demographics
NPI:1144475047
Name:GUTTER, BELEN (PHD)
Entity type:Individual
Prefix:
First Name:BELEN
Middle Name:
Last Name:GUTTER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 251
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30031-0251
Mailing Address - Country:US
Mailing Address - Phone:404-423-5775
Mailing Address - Fax:
Practice Address - Street 1:315 W PONCE DE LEON AVE
Practice Address - Street 2:SUITE 480
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2400
Practice Address - Country:US
Practice Address - Phone:404-423-5775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSYCH002745103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA161669152BMedicaid