Provider Demographics
NPI:1871618801
Name:OWENS GUTIERRE, MIRIAM P (LCPC)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:P
Last Name:OWENS GUTIERRE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:422 TAG WAY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-6288
Mailing Address - Country:US
Mailing Address - Phone:815-444-6400
Mailing Address - Fax:815-444-6816
Practice Address - Street 1:422 TAG WAY
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-6288
Practice Address - Country:US
Practice Address - Phone:815-444-6400
Practice Address - Fax:815-444-6816
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3636144473OtherEIN