Provider Demographics
NPI:1144511940
Name:GUTIERREZ, DIANA (LICENSED CLINICAL SO)
Entity type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:LICENSED CLINICAL SO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 W. WASHINGTON
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-343-3688
Mailing Address - Fax:208-343-8475
Practice Address - Street 1:720 W. WASHINGTON
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-343-3688
Practice Address - Fax:208-343-8475
Is Sole Proprietor?:No
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW291891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical