Healthcare Provider Details

I. General information

NPI: 1538195987
Provider Name (Legal Business Name): MICHAEL JOHN KUTTNER PH.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2006
Last Update Date: 04/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 SOUTH AVE SUITE 210
ROCHESTER NY
14620-2740
US

IV. Provider business mailing address

448 WHITE SPRUCE BLVD
ROCHESTER NY
14623-1608
US

V. Phone/Fax

Practice location:
  • Phone: 585-256-3440
  • Fax:
Mailing address:
  • Phone: 585-256-3440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number009564
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: