Provider Demographics
NPI:1235938234
Name:GUTIERREZ, BERNADETTE G (CPSW, CCSS,)
Entity type:Individual
Prefix:
First Name:BERNADETTE
Middle Name:G
Last Name:GUTIERREZ
Suffix:
Gender:
Credentials:CPSW, CCSS,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 N RIVERSIDE DR STE 6
Mailing Address - Street 2:
Mailing Address - City:ESPANOLA
Mailing Address - State:NM
Mailing Address - Zip Code:87532-2916
Mailing Address - Country:US
Mailing Address - Phone:505-367-3500
Mailing Address - Fax:505-367-3503
Practice Address - Street 1:908 N RIVERSIDE DR STE 6
Practice Address - Street 2:
Practice Address - City:ESPANOLA
Practice Address - State:NM
Practice Address - Zip Code:87532-2916
Practice Address - Country:US
Practice Address - Phone:505-367-3500
Practice Address - Fax:505-367-3503
Is Sole Proprietor?:No
Enumeration Date:2025-03-11
Last Update Date:2025-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 175T00000X
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No175T00000XOther Service ProvidersPeer Specialist