Provider Demographics
NPI:1689550329
Name:GUTIERREZ CANALES, IVANIA GUISSELLE
Entity type:Individual
Prefix:
First Name:IVANIA
Middle Name:GUISSELLE
Last Name:GUTIERREZ CANALES
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 1:109 SW 115TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1052
Mailing Address - Country:US
Mailing Address - Phone:786-818-3046
Mailing Address - Fax:786-818-3046
Practice Address - Street 1:109 SW 115TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1052
Practice Address - Country:US
Practice Address - Phone:786-818-3046
Practice Address - Fax:786-818-3046
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-15
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-457869106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician