Healthcare Provider Details

I. General information

NPI: 1053628248
Provider Name (Legal Business Name): KELLY STEWART HUTNER PSY.D., HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2010
Last Update Date: 10/11/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11143 PARKVIEW PLAZA DR STE 320
FORT WAYNE IN
46845-1728
US

IV. Provider business mailing address

3702 NEW VISION DR BLDG B
FORT WAYNE IN
46845-1703
US

V. Phone/Fax

Practice location:
  • Phone: 260-266-5370
  • Fax: 260-266-5379
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20041507A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: