Healthcare Provider Details

I. General information

NPI: 1700944782
Provider Name (Legal Business Name): MARK KUTNER PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13711 73RD TER
FLUSHING NY
11367-2303
US

IV. Provider business mailing address

13711 73RD TER
FLUSHING NY
11367-2303
US

V. Phone/Fax

Practice location:
  • Phone: 718-575-3510
  • Fax: 718-575-0391
Mailing address:
  • Phone: 718-575-3510
  • Fax: 718-575-0391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number008766-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: