Healthcare Provider Details

I. General information

NPI: 1568138196
Provider Name (Legal Business Name): ELLYN KUTCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 11/07/2022
Certification Date: 11/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 BERTHOLET BLVD STE 301
VALPARAISO IN
46383-7959
US

IV. Provider business mailing address

2801 BERTHOLET BLVD STE 301
VALPARAISO IN
46383-7959
US

V. Phone/Fax

Practice location:
  • Phone: 219-477-9239
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number34009132A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: