Healthcare Provider Details

I. General information

NPI: 1659336865
Provider Name (Legal Business Name): DANIEL JOSEPH TUTTY PHD,LCSW,LADC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 170
FT.IRWIN CA
92310
US

IV. Provider business mailing address

13228 IBSEN LN
VICTORVILLE CA
92392-8315
US

V. Phone/Fax

Practice location:
  • Phone: 760-380-3631
  • Fax:
Mailing address:
  • Phone: 760-245-9203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number01542-C
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: