Healthcare Provider Details

I. General information

NPI: 1043492176
Provider Name (Legal Business Name): GLENN EDWARD KUTZLI MA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 36TH ST SE
KENTWOOD MI
49512-2809
US

IV. Provider business mailing address

3333 36TH ST SE
KENTWOOD MI
49512-2809
US

V. Phone/Fax

Practice location:
  • Phone: 616-954-3540
  • Fax:
Mailing address:
  • Phone: 616-954-3540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401008162
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: