Provider Demographics
NPI:1659117265
Name:GUTIERREZ BENITEZ, ANTONIA (LPC)
Entity type:Individual
Prefix:
First Name:ANTONIA
Middle Name:
Last Name:GUTIERREZ BENITEZ
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E MAIN ST STE 211
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2017
Mailing Address - Country:US
Mailing Address - Phone:208-357-3104
Mailing Address - Fax:888-990-2826
Practice Address - Street 1:101 E MAIN ST STE 211
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2017
Practice Address - Country:US
Practice Address - Phone:208-357-3104
Practice Address - Fax:888-990-2826
Is Sole Proprietor?:No
Enumeration Date:2024-07-02
Last Update Date:2024-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-10649101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health