Healthcare Provider Details

I. General information

NPI: 1003238155
Provider Name (Legal Business Name): HENRY AUGUSTUS LUTTERODT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: HENRY AUGUSTUS LUTTERODT MS

II. Dates (important events)

Enumeration Date: 01/08/2014
Last Update Date: 01/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 SESSIONS LN
KENNER LA
70065-2962
US

IV. Provider business mailing address

912 SESSIONS LN
KENNER LA
70065-2962
US

V. Phone/Fax

Practice location:
  • Phone: 336-457-4153
  • Fax:
Mailing address:
  • Phone: 336-457-4153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: