MEDICARE: JOHN G KUTINAC, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC1900X	Counseling Psychologist	PA9501	NM

General Provider Information

NPI Number	:	1386025096
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JOHN G KUTINAC, INC

Provider Business Mailing Address
First Line	:	1155 S TELSHOR BLVD
Second Line	:	SUITE 200
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-1009
Country	:	US
Telephone Number	:	575-522-8002
Fax Number	:	575-522-8027

Provider Business Practice Location Address
First Line	:	1155 S TELSHOR BLVD
Second Line	:	SUITE 200
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-1009
Country	:	US
Telephone Number	:	575-522-8002
Fax Number	:	575-522-8027

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN G KUTINAC JR.
Credential	:	MA PA LPCC
Telephone Number	:	575-522-8002

Provider Enumeration Date	:	06/18/2015
Last Update Date	:	06/18/2015

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