Provider Demographics
NPI:1053702605
Name:GUTIERREZ, VICTORIA (PTA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:GUTIERREZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6826 DORIANA ST
Mailing Address - Street 2:APT 19
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-2035
Mailing Address - Country:US
Mailing Address - Phone:619-646-9703
Mailing Address - Fax:
Practice Address - Street 1:4435 EASTGATE MALL
Practice Address - Street 2:STE 120
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1982
Practice Address - Country:US
Practice Address - Phone:858-587-8669
Practice Address - Fax:858-587-8675
Is Sole Proprietor?:No
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10176225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant