Provider Demographics
NPI:1497586747
Name:LEOCADIO GUTIERREZ, ALMA BERENICE
Entity type:Individual
Prefix:
First Name:ALMA
Middle Name:BERENICE
Last Name:LEOCADIO GUTIERREZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 HEMLOCK ST
Mailing Address - Street 2:
Mailing Address - City:SELDEN
Mailing Address - State:NY
Mailing Address - Zip Code:11784-1328
Mailing Address - Country:US
Mailing Address - Phone:631-880-7285
Mailing Address - Fax:
Practice Address - Street 1:78 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:SELDEN
Practice Address - State:NY
Practice Address - Zip Code:11784-1328
Practice Address - Country:US
Practice Address - Phone:631-880-7285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1832047241174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist